learn how to convert lab values to words

LECTURE 1

ACID BASES

¥learn how to convert lab values to words ¥the rule of the BÕs
 = if the pH and the BiCarb are both in the same 
 direction -> metabolic


Hint: draw arrows beside each to see directions


• down = acidosis

• up = alkalosis

• respiratory -> has no b in it; if in other directions 


(or if bicarb is normal value)


• KNOW NORMAL pH, BiCarb, CO2 


¥Hint: DONÕT MEMORIZE LISTSÉknow principles

(they test knowledge of principles by having you generate lists..)

• for Òselect allÓ questions

• ex. in general/principle what do opioids/pain 


meds do? = sedate you, CNS depressors


• ex. what does dilaudid do? donÕt memorize speciÞcs 


or a list of dilaudid, know principles of opioids (such 
 as sedation, CNS depression -> lethargy, ßaccidity, 
 reßex +1, hypo-reßexia, obtunded)


• boards donÕt test by lists because all books/


classes have different lists


¥principles of S&S acid bases: as the pH goes so

goes my patient (except K+)


• pH up = PT up -> body system gets more 


irritable, hyper-excitable (EXCEPT K+)
 -> alkalosis - think of a body system and go 


high: hyper-reßexive (+3, +4 [2 is normal]), 


tachypnea, tachycardia, borborygmi, seizure


• pH down = PT down -> body systems shut 


down (EXCEPT K+)


-> acidosis - think of a system and go low: 


hypo-reßexive (+1, 0), bradycardia, lethargy, 
 obtunded, paralytic illeus, respiratory arrest ¥ex. which acid-base disorders need an ambu-bag at the bedside? = acidosis (resp. arrest) ¥ex. which acid-base disorders need suction at the bedside? = alkalosis (seize and aspirate) ¥Mac Kussmaul - KussmaulÕs (compensatory respiratory mechanism) is only present in only 1 of the 4 metabolic (acid-base) disorders


• M = metabolic AC = acidosis


¥most common mistake with select all questions = selecting one more than you should (stop when you select the ones you know! donÕt get caught up on the Òcould beÕsÓ)

¥Hint: donÕt select none or all on select all that apply

questions (never only one and never all)

¥Causes of Acid-Base Imbalance:


• scenarios and what acid-base disorder would 


result (what would cause an imbalance)
 ** DONÕT MIX UP S&S and CAUSATION


• often what causes something is the opposite of the S&S

• ex. diarrhea will cause a metabolic acidosis but once 


you are acidotic your bowel shuts down and you get a 
 paralytic illeus ¥

when you get scenarios: 


-> if itÕs a lung scenario = respiratory


• then check if the client is over-ventilating 


(alkalosis) or under-ventilating (acidosis)


• remember to look at the words (ex. over, under, 


ventilating) -> Òas the pH goes so goes my PTÓ
 -> VENTILATING DOESNÕT MEAN RESPIRATORY 
 RATE; resp. rate is irrelevant w/ acid-base, 
 ventilation has to do with gas exchange not resp. 
 rate (look at the SaO2 -> if your resp. rate is fast 
 but SaO2 is low you are under-ventilating)
 -> ex. PCA pump - What acid-base disorder 
 indicates they need to come off of it? = respiratory 
 acidosis (resp. depression -> resp. arrest)
 Ñ> if itÕs not lung, itÕs metabolic ¥ metabolic alkalosis - really only one scenario = if the PT has prolonged gastric vomiting/suctioning


• because you are losing ACID

• ex. GI surgery w/ NG tube with suctioning for 

• days; hyperemesis graviderum

• otherwise everything else that isnÕt lung you 


pick metabolic acidosis (DEFAULT)


• ex. hyperemesis graviderum w/ dehydration 


acute renal failure, infantile diarrhea

¥remember, you only have 4 to pick from:


• respiratory alkalosis - respiratory acidosis

• metabolic alkalosis - metabolic acidosis

¥pay more attention to the modifying phrases than the original noun


• ex. person w/ OCD who is now psychotic (psychotic 


trumps OCD); hyperemesis with dehydration (pay 
 attention to dehydration)

VENTILATION

¥ventilators -> know alarm systems (you set it up so that the machine doesnÕt use less than or more than speciÞc amounts of pressure)


• high pressure alarm = increased resistance 


to airßow (the machine has to push too hard to 
 get air into lungs)


- from obstructions: 


• kinks in tubing (unkink it)


ii. water condensation in tube (empty it!)
 iii. mucous secretions in the airway (change 
 positions/turn, C&DB, and THEN suction)
 *** suction is only PRN!!!
 -> priority questions = you would check 
 kinks Þrst, suction is not Þrst
 


• low pressure alarm = decreased resistance 


to airßow (the machine had to work too little 
 to push air into lungs)


- from disconnections:


• main tubing (reconnect it duh!)


ii. O2 sensor tubing (which senses FiO2 at 
 the airway/trach area; black coated wire 
 coming from machine right along the 
 tubing - reconnect!) ¥ventilators -> know blood gases


• resp. alkalosis = ventilation settings might be 


set too high (OVER-VENTILATING)


• resp. acidosis = ventilation settings might be set 


too low (UNDER-VENTILATING) ¥ex. weaning a PT off ventilator -> should not be under-ventilated, they need the ventilator; if they are over-ventilating then they can be weaned ¥never pick an answer where you donÕt do something and someone else has to do something

LECTURE 2

ABUSE (Psych and Med-Surge) Psychological Aspect/Psycho-Dynamics ¥# 1 psychological problem is the same in any/all abusive situations = DENIAL


• abusers have an inÞnite capacity for denial so that 


they can continue the behavior w/o answering for it ¥can use the alcoholism rules for any abuse


• ex. # 1 psych problem in child abuse, gambling or 


cocaine abuse is denial ¥why is denial the problem? HOW CAN YOU TREAT

SOMEONE WHO DENIES/DOESNÕT RECOGNIZE

THEY HAVE A PROBLEM

¥denial = refusal to accept the reality of a problem ¥treat denial by CONFRONTING the problem (itÕs not the same as aggression which attacks the person, not the problem) = they DENY you CONFRONT 


• pointing out to the person the difference between 


what they say and what they do


- Hint: never pick answers that attack the person


-> ex. bad answers have bad pronouns - ÒyouÓ
 -> ex. good answers have good pronouns - ÒIÓ, ÒweÓ
 -> ex. Òyou wrote the order wrongÓ vs. ÒIÕm having 
 difÞculty interpreting what you wantÓ ¥loss and grief -> for this denial you must SUPPORT it


• DABDA = denial, anger, bargaining, depression, acceptance

¥Hint: for questions about denial, you must look to see

if it is LOSS or ABUSE


• loss/grief = support

• abuse = confront

¥#2 psychological problem in abuse = DEPENDENCY,

CO-DEPENDENCY 


• dependency = when the abuser gets signiÞcant other 


to do things for them or make decisions for them
 -> the dependent = abuser


• co-dependency = when the signiÞcant other derives 


positive self-esteem from making decisions for or 
 doing things for the abuser
 -> the abuser gets a life w/o responsibilities
 -> the sig. other gets positive self-esteem (which is 
 why they canÕt get out of the relationship) ¥how do you treat it?


• set limits and enforce them


-> start teaching sig. other to say NO (and they 
 have to keep doing it)


• must also work on the self-esteem of the co-dependent 


(ex. IÕm a good person because IÕm saying ÒnoÓ) ¥manipulation = when the abuser gets the sig. other to do things for them that are not in the best interest of the sig. other


• the nature of the act is dangerous/harmful

• how is manipulation like dependency?


-> in both the abuser is getting the other person to 
 do something for them


• how do you tell the difference between manipulation 


& dependency?
 -> NEUTRAL vs. NEGATIVE (look at what theyÕre 
 being asked to do)
 -> if the sig. other is being asked to do something 
 neutral (no harm) its dependency/co-dependency
 -> if the sig. other is being asked to do something 
 that will harm them or is dangerous to them they 
 are manipulated ¥how do you treat manipulation?


• set limits and enforce them -> ÒNOÓ

• easier to treat than dependency/co-dependency 


because no one likes to be manipulated (no positive 
 self-esteem issue going on) ¥ex. how many PTÕs do you have w/ denial? = 1
 ex. how many PTÕs do you have w/ dependency/co-
 dependency = 2
 ex. how many PTÕs do you have w/ manipulation = 1 Alcoholism
 WernickeÕs & KorsakoffÕs


• typically separate BUT boards lumps them together

• wernickeÕs = encephalopathy

• korsakoffÕs = psychosis (lose touch with reality)


-> tend to go together, Þnd them in the same PT

¥Wernicke KorsakoffÕs syndrome:


• psychosis induced by Vit. B1 (Thiamine) deÞciency

• lose touch w/ reality, go insane because of no B1

• primary symptom -> amnesia w/ confabulation

• signiÞcant memory loss w/ making up stories

• they believe their stories

¥How do you deal w/ these PTÕs?


• bad way = confrontation (because they believe what 


they are saying and canÕt see reality)


• good way = redirection (take what the PT canÕt do 


and channel it into something they can do)

¥Characteristics of Wenicke KorsakoffÕs:


• itÕs preventable = take Vit. B1 (co-enzyme needed 


for the metabolism of alcohol which keeps alcohol 
 from accumulating and destroying brain cells)


• PT doesnÕt have to stop drinking

• itÕs arrestable = can stop it from getting worse by 


taking Vit. B1


• also not necessary to stop drinking


c) itÕs irreversible (70% of cases) -> Hint: On boards, 


answer w/ the majority (ex. if something is majority 
 of the time fatal, you say itÕs fatal even if 5% of the 
 time itÕs not)

¥Drugs for Alcoholism:


DISULFIRAM (Antabuse)
 = aversion therapy -> want PTÕs to develop a gut 
 hatred for alcohol
 -> interacts w/ alcohol in the blood to make you very ill
 -> works in theory better than in reality


-> onset & duration: 2 weeks (so if you want to 


drink again, wait 2 weeks)


• PT teaching = avoid ALL forms of alcohol to avoid 


nausea, vomiting & possibly death
 -> including mouthwash, aftershaves/colognes/perfumes 
 (topical stuff will make them nauseous), insect 
 repellants, any OTC that ends with Ò-elixerÓ, alcohol-
 based hand sanitizers, uncooked (no-bake) icings 
 which have vanilla extract, red wine vinaigrette 
 ¥

Overdoses & Withdrawals:


• every abused drug is either an UPPER or DOWNER


-> the other drugs donÕt do anything
 -> #1 abused class of drug that is not an upper or 
 downer = laxatives in the elderly


• Þrst establish if the drug is an upper or downer

• uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic 


hallucinogens), methamphetamines, adderol (ADD drug)


• S&S -> make you go up; euphoria, tachycardia, 


restlessness, irritability, diarrhea, borborygmi, 
 hyper-reßexia, spastic, seize (need suction) 


• downers = donÕt memorize names ->

anything that 
 is not an upper is a downer! if you donÕt know what 
 the med is, you have a high chance that itÕs a 
 downer if itÕs not part of the uppers list


• S&S -> make you go down; lethargy, respiratory 


depression (& arrest) 
 - ex. The PT is high on cocaine. What is critical to assess?
 -> NOT resps below 12 because they will be high
 -> maybe check reßexes


• are they talking about overdose or withdrawal

• overdose/intoxication = too much

• withdrawal = not enough

• ex. the PT has overdosed on an upper -> pick the 


S&S of too much upper


• ex. the PT has overdosed on a downer -> pick the 


S&S of too much downer


• ex. the PT is withdrawing from an upper -> not 


enough upper makes everything go down


• ex. the PT is withdrawing from a downer -> not 


enough downer makes everything go up ¥upper overdose looks like = downer withdrawal ¥downer overdose looks like = upper withdrawal ¥ In what 2 situations would resp. depression & arrest

be your highest priority:


• downer overdose

• upper withdrawal

¥In what 2 situations would seizure be the biggest risk:


• upper overdose

• downer withdrawal


¥Drug Abuse in the Newborn:


• always assume intoxication, NOT withdrawal at birth

• after 24 hrs -> withdrawal

• ex. caring for infant of a Quaalude addicted mom 24 


hrs. after birth, select all that apply:


-> downer withdrawal so everything is up = exaggerated 
 startle, seizing, high pitched/shrill cry ¥ Alcohol Withdrawal Syndrome vs. Delirium Tremens


• they are both different! not the same

• every alcoholic goes through withdrawal 24 hrs. 


after they stop drinking


• only a minority get delirium tremens

• timeframe -> 72 hrs. (alcohol withdrawal comes 1st)

• alcohol withdrawal syndrome ALWAYS precedes 


delirium tremens, BUT delirium tremens does not 
 always follow alcohol withdrawal syndrome


b) AWS is not life-threatening; DTÕs can kill you


c) PTÕs w/ AWS are not a danger to self/others; PTÕs 


w/ DTÕs are dangerous to self/others


• they are withdrawing from a downer so they will 


be exhibiting upper S&S


• DTÕs are dangerous

¥RNÕs can accept but RPNÕs canÕt (because PT is unstable)


• on med-surge, the RN who takes them must decrease 


their workload (i.e. reduce PT load if they take a DT PT)
 ->

Hint: on boards, the setting is always perfect 


(i.e. enough staff/time/resources on the unit etc.) 
 Differences in Care

AWS DT

Diet Regular dietNPO/clear liquids
 (because of risk for seizures which can cause risk of aspiration) Room Semi-private anywhere on the unit Private near nurses station (dangerous & unstable) AmbulationUp ad libRestricted bed rest -> no bathroom privileges (use bedpans/urinals) RestraintsNo restraints (because not dangerous) Restraints (because dangerous)


• not soft wrist or 4 point soft 


because theyÕll get out


• need to be in vest or 2-pt. locked 


leathers (opposite 1 arm & leg, 
 rotate Q2hrs, lock the free 
 limbs 1st before releasing the 
 locked ones) They both get ANTI-HYPERTENSIVES &

TRANQUILIZERS


• because everything is up (downer withdrawal)


They both get MULTIVITAMIN w/ B1