3. Skill- exam proficiency

Recording 1:

• Knowledge
• Confidence
• Skill- exam proficiency

 “You can apply what you don’t know, you have to apply what you do know.”  Have to achieve a little less than average on this test to pass. Boards does not test your knowledge of lists, it tests your knowledge of principles.

Acid/Base Balance:

 Lab values  convert to words

 ROME

 If the pH and the bicarb are both in the same direction = metabolic  If they are in different directions = respiratory  pH= acidoic and alkalosis (7.35-7.45)  Bicarb (HCO3)= 22-26 (2+2+2=6)  Up and normal is not the same direction so it would still be respiratory  Principle: As the pH goes, so does my patient (when pH goes up, patient goes up & when pH goes down, patient gowns down) EXCEPT for potassium

• Alkalosis- irritability, hyper-reflexes (3,4), tachypnea, tachycardia, borborygmi

ileus (increased bowel sounds)

• Acidosis- hyporeflexia, bradycardia, lethargy, obtunded, paralytic ileus, coma

 What acid base imbalance patient needs an ambu bag at the bedside? Acidosis- respiratory distress  What acid base imbalance patient needs suction at the bedside? Alkalosis- bc they could seize and aspirate  Kussmual respirations- Mac Kussmual = metabolic acidosis  Adynamic= without movement

Causes of acid/base imbalance:

 What causes something is the opposite of what the signs and symptoms are. Is it Lung? – Respiratory problem  Is the patient over ventilating (alkalosis) or under ventilating (acidosis)?

• Vent= respiratory
• Over= alkalosis
• Under= acidosis

 Ventilation= gas exchange (SaO2) NOT respiratory rate. If it is NOT LUNG= metabolic  Metabolic alkalosis= prolonged gastric vomiting or suctioning (only things that are metabolic alkalosis) b/c you are loosing acid  For everything else, that isn’t lung or vomiting/suctioning pick metabolic acidosis.

 IF YOU DON’T KNOW WHAT IT IS  METABOLC ACIDOSIS

VENTILATORS:

 Alarms

• High pressure- triggered by increased resistance to airflow (machine is having to

push to hard to get hair into the lungs).

 Obstructions: (click & drag)

 Kinks in tubing unkink the tubing  Water condensation empty the water

 Mucous secretions in airway turn/cough/deep breath, then suction (ONLY SUCTION AS NEEDED)

• Low pressure- triggered by decreased resistance to airflow (machine is saying

“that was too easy”

 Disconnections:

 Disconnection of main tubing  reconnect  Oxygen sensor tubing  plug sensor back in

 HOLD

 Respiratory Alkalosis- over ventilating  ventilator setting may be too high  Respiratory Acidosis- under ventilating  ventilator settings are too low

Recording 2:

ALCOHOLISM

Psychodynamics:

 Number one problem in abuse is DENIAL

• You can use the alcohol rule in any abuse
• Number one bc you cant treat someone that denies they have a problem
• Denial- refusal to accept reality of a problem
• You treat denial by CONFRONTING it- difference between what they say and

what they do (“you say you aren’t an alcoholic but you already drank a 6 pack and its 10 o clock in the morning”)

• Aggression attacks the person, confrontation attacks the problem

 ON BOARDS NEVER ATTACK PERSON

o When confronting an issue with staff:

 Good answer = “I”  Bad answer= “you”  Ex: NOT-“you wrote the order incorrectly” instead, “I am having a difficult time interpreting what you want”  DABDA- denial, anger, bargaining, depression, acceptance (stages of grief

• Denial is healthy and normal in loss and grief
• You don’t confront in this situation you support it

 When you get a question about denial you have to determine if it is loss or abuse

• Abuse- CONFRONT
• Loss- SUPPORT

 Number two problem in abuse:

• Dependency- when abuser makes significant other do things for them or make

decisions for them

 Ex: “would you call my boss”

 Abuser= dependent

• Codependency- when significant other derives positive self esteem from making

decisions for the abuser  Ex: “Aren’t I such a good spouse because I did that, cause I don’t know anyone else that would do it for that jerk”

• How to treat it?

 SET LIMITS AND ENFORCE THEM  say “NO” to those things that you are feeding into

 Work on the self esteem for the codependent person  “I’m saying no, and I’m a good person because I’m saying NO”  MANIPULATION: when abuser gets significant other to do things for him/her when it is not in the best interest of the significant other

• Nature of the act is dangerous or harmful

o Different from dependency:

 If what significant other is asked to do is neutral = dependency/codependency

 Ex: 49 year old alcoholic asks 50 year old husband to go buy

alcohol (not harmful for 50 year old man to go buy alcohol)  If what significant other is asked to do is harmful = manipulation

 Ex: 49 year old alcoholic gets 17 year old daughter to go buy

alcohol (dangerous b/c its illegal for 17 year old to buy alcohol)

• How to treat?

 SET LIMITS AND ENFORCE THEM

 Its easier to treat b/c no one likes to be manipulated and there is no self esteem issue

Alcoholism Terms:

 Wernicke’s- encephalopathy  Korsakoffs- psychosis  Wernicke-Korsakoff- number one psychosis induced by vitamin B1 or thiamine deficiency (loose touch with reality, go insane, b/c you have a deficiency in B1)

• Symptoms- amnesia (memory loss) with confabulation (making up stories)
• REDIRECT- takes what he can’t do and rechannel to something he can do.

 Ex: If he says he wants to go to Obama’s cabinet meeting  you redirect

by saying “why don’t you take a shower and we will watch CNN to see what’s going on at the white house today.”  DON’T PRESENT REALITY- they cant learn reality

o Characteristics:

 Preventable- take vitamin B1  Stop it from getting worse by taking B1  Irreversible

Drugs used to treat alcoholism:

 Antabuse (Disulfiram)

• Aversion therapy- develop a hatred for alcohol
• Creates an unpleasant reaction to alcohol
• Onset & duration- 2 weeks
• Patient teaching- avoid all forms of alcohol including mouthwash, aftershave,

perfume & cologne, insect repellents, any OC that ends in –elixir, alcohol based hand sanitizers, uncooked icings (vanilla extract), red wine vinaigrette

Overdose/Withdrawal:

 Every ABUSED drug is either an upper or a downer

• First question- upper or a downer?

 Uppers- caffeine, cocaine, PCP/LSD (hallucinogens), methamphetamines (crystal meth), Adderall  Signs and symptoms- things go “up”  euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi bowels, 3-4 reflexes, seizure (suction @ bedside)

 Downers- everything that isn’t upper is a downer  Signs and symptoms- things go “down”  lethargic, respiratory arrest (ambu bag @ bedside)

• Second Question- overdose or withdrawal?

 Overdose/intoxication- too much  Withdrawal- not enough  If you don’t have enough upper makes everything go down  If you don’t have enough downer makes everything go up

 UPPER OVERDOSE LOOKS LIKE DOWNER WITHDRAWL

 DOWNER OVERDOSE LOOKS LIKE UPPER WITHDRAWL

 Respiratory arrest/depression- downer overdose & upper withdrawal  Seizure- upper overdose, downer withdrawal  Number one most abused class of drug that is not an upper or downer  LAXATIVES in elderly

Drug Addiction in Newborn:

 ALWAYS assume intoxication NOT withdrawal at birth  After 24 hours assume withdrawal

Alcohol withdrawal syndrome vs. Delirium tremens:

 Every alcoholic goes through alcohol withdrawal 24 hours after they stop drinking  Only a minority get delirium tremens- 72 hours after stop drinking  Alcohol withdrawal syndrome always precedes DT’s but DT’s don’t always follow alcohol withdrawal syndrome  AWS is not life threatening, DT’s can kill you  Patient with AWS is not dangerous to self or others DT’s ARE.AWS DT’s  Regular diet  Semi-private anywhere  Up add-lib  No restraints  NPO or clear liquids (seizure)  Private near nursing station  Restricted bedrest  Restraints- vest or 2 point lock leathers

BOTH:

 Antihypertensive- b/c everything is going up  Tranquilizer- b/c they are up  Multivitamin containing B1- to prevent Wernicke-Korsakoff

DRUGS:

 Aminoglycosides- dangerous

• A MEAN OLD MYCIN (mean old infection)  they are antibiotics used to treat

serious life threatening resistance gram negative infections

• End in –mycin

o Not all -mycin drugs are aminoglycosides:

 Erythromycin  Azithromycin  Clarithromycin  “If it has “thro” throw it off the list”

• If it ends in “mycin” it’s a mean old mycin, and if it has “thro” throw it off the list.