3.Skill- exam proficiency

Recording 1:

1.Knowledge 2.Confidence 3.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 oAlkalosis- irritability, hyper-reflexes (3,4), tachypnea, tachycardia, borborygmi ileus (increased bowel sounds) oAcidosis- 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)?oVent= respiratory oOver= alkalosis oUnder= 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 oHigh 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) oLow 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 oYou can use the alcohol rule in any abuse oNumber one bc you cant treat someone that denies they have a problem oDenial- refusal to accept reality of a problem oYou 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”) oAggression attacks the person, confrontation attacks the problem

ON BOARDS NEVER ATTACK PERSON

oWhen 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 oDenial is healthy and normal in loss and grief oYou 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 oAbuse- CONFRONT oLoss- SUPPORT

Number two problem in abuse:

oDependency- when abuser makes significant other do things for them or make decisions for them

Ex: “would you call my boss”

Abuser= dependent oCodependency- 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” oHow 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 oNature of the act is dangerous or harmful

oDifferent 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) oHow 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) oSymptoms- amnesia (memory loss) with confabulation (making up stories) oREDIRECT- 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

oCharacteristics:

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

Drugs used to treat alcoholism:

Antabuse (Disulfiram) oAversion therapy- develop a hatred for alcohol oCreates an unpleasant reaction to alcohol oOnset & duration- 2 weeks oPatient 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 oFirst 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)

oSecond 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.AWSDT’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 oA MEAN OLD MYCIN (mean old infection)  they are antibiotics used to treat serious life threatening resistance gram negative infections oEnd in –mycin

oNot all -mycin drugs are aminoglycosides:

Erythromycin Azithromycin Clarithromycin “If it has “thro” throw it off the list” oIf it ends in “mycin” it’s a mean old mycin, and if it has “thro” throw it off the list.

oToxic effects:

Mycin = mice = ears = ototoxic (hearing, ringing in ear- tinnitus, vertigo/dizziness)