learn how to convert lab values to words

LECTURE 1

ACID BASES

• learn how to convert lab values to words • the rule of theB’s = if the pH and theBiCarb areboth in the same direction ->metabolic

Hint:draw arrows beside each to see directions

• down =acidosis
• up =alkalosis
• respiratory -> has nobin it; if in other directions

(or if bicarb is normal value) -KNOW NORMAL pH, BiCarb, CO2

•Hint:DON’T MEMORIZE LISTS…know principles

(they test knowledge of principles by having you generate lists..)- for “select all” questions

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

meds do? = sedate you, CNS depressors* ex.what does dilaudid do?don’t memorize specifics or a list of dilaudid, know principles of opioids(such as sedation, CNS depression -> lethargy, flaccidity, reflex +1, hypo-reflexia, obtunded)

• boards don’t 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-reflexive (+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-reflexive (+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- Kussmaul’s (compensatory respiratory mechanism) is only present inonly 1of 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! don’t get caught up on the “could be’s”)

• Hint:don’t selectnoneorallon 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) ** DON’T MIX UP S&S and CAUSATION - often what causes something is theoppositeof the S&S

• ex.

diarrhea willcausea metabolic acidosis but once you are acidotic your bowel shuts down and you get a paralytic illeus •

when you get scenarios:

->if it’s alungscenario= respiratory

• then check if the client isover-ventilating

(alkalosis)orunder-ventilating (acidosis)- remember to look at the words (ex. over, under, ventilating) -> “as the pH goes so goes my PT” ->

VENTILATING DOESN’T MEAN RESPIRATORY RATE;

resp. rate isirrelevantw/ 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) —>if it’s not lung, it’s metabolic • metabolic alkalosis- really only one scenario =if the PT has prolonged gastric vomiting/suctioning- because you arelosing ACID

• ex. GI surgery w/ NG tube with suctioning for
• days; hyperemesis graviderum
• otherwise everything else that isn’t lung you

pickmetabolic 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 themodifying phrasesthan 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 doesn’t useless thanormore thanspecific amounts of pressure) a)high pressure alarm=increased resistance to airflow (the machine has to push too hard to get air into lungs)

- fromobstructions:

• kinks in tubing (unkink it)

ii. water condensation in tube (empty it!) iii.mucous secretions in the airway (change positions/turn, C&DB,and THENsuction) ***

suction is only PRN!!!-> priority questions = you would check kinks first, suction is not first b)low pressure alarm=decreased resistance to airflow (the machine had to work too little to push air into lungs)

- fromdisconnections:

• 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 don’t 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 infinite 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/DOESN’T RECOGNIZE

THEY HAVE A PROBLEM

• denial = refusal to accept the reality of a problem • treat denial by CONFRONTING the problem (it’s not the same asaggressionwhich 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 - “you” -> ex.good answers have good pronouns - “I”, “we” -> ex.“you wrote the order wrong” vs. “I’m having difficulty interpreting what you want” •loss and grief -> for this denial you mustSUPPORTit

• 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 significant other to do things for them or make decisions for them-> the dependent = abuser -co-dependency= when the significant 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 can’t 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 workontheself-esteemoftheco-dependent

(ex.I’magoodperson becauseI’msaying “no”)• 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 isdangerous/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 they’re 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 -> “NO”
• easier to treat than dependency/co-dependency

because no one likes to be manipulated (no positive self-esteem issue going on) •ex. how many PT’s do you have w/ denial? = 1 ex.how many PT’s do you have w/ dependency/co- dependency = 2 ex. how many PT’s do you have w/ manipulation = 1 Alcoholism Wernicke’s & Korsakoff’s

• typically separate BUT boards lumps them

together -wernicke’s = encephalopathy -korsakoff’s = psychosis (lose touch with reality)-> tend to go together, find them in the

same PT •Wernicke Korsakoff’s syndrome:

• psychosis induced byVit. B1 (Thiamine) deficiency
• lose touch w/ reality, go insane because of no B1 b)

primary symptom ->amnesia w/ confabulation- significant memory loss w/ making up stories - they believe their stories • How do you deal w/ these PT’s?

• bad way = confrontation (because they believe what

they are saying and can’t see reality)

• good way =redirection(take what the PT can’t do

and channel it into something they can do) •

Characteristics of Wenicke Korsakoff’s:a)it’s

preventable= take Vit. B1 (co-enzyme needed for the metabolism of alcohol which keeps alcohol from accumulating and destroying brain cells) * PT doesn’t have to stop drinking b)it’s arrestable= can stop it from getting worse by taking Vit. B1

• also not necessary to stop drinking

c)it’s irreversible(70% of cases) ->Hint: On boards,

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

•Drugs for Alcoholism:

DISULFIRAM(Antabuse) =aversion therapy-> want PT’s to develop a gut hatred for alcohol -> interactsw/alcoholinthebloodtomake you veryill -> 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 “-elixer”, alcohol- based hand sanitizers, uncooked (no-bake) icings which havevanilla extract, red wine vinaigrette •

Overdoses & Withdrawals:

-everyabuseddrug is either anUPPERor DOWNER -> the other drugs don’t do anything -> #1 abused class of drug that is not an upper or downer = laxatives in the elderly

• first establish if the drug is anupperordowner-

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-reflexia, spastic, seize (need suction) -downers= don’t memorize names -> anything that is not an upper is a downer! if you don’t know what the med is, you have a high chance that it’s a downer if it’s 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 reflexesb) are they talking aboutoverdoseor 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,NOTwithdrawal at birth-after24 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

a)everyalcoholic goes through withdrawal24 hrs.

after they stop drinking

• only aminorityget 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; DT’s can kill youc)PT’s w/ AWS are not a danger to self/others; PT’s w/ DT’s are dangerous to self/others

• they are withdrawing from a downer so they will

be exhibiting upper S&S

• DT’s are dangerous

Differenc es in Care

AWS DT

Diet Regular diet NPO/clear liquids (because of risk for seizures which can cause risk of aspiration) Room Semi-priv ate anywhere on the unit Private near nurses station (dangerous & unstable) Ambulatio n Up ad libRestricted bed rest -> no bathroom privileges (use bedpans/urinals) Restraint s No restraints (because not dangerous ) Restraints (because dangerous) - not soft wrist or

• point soft because they’ll

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 • RN’s can accept but RPN’s can’t (because PT is unstable)-onmed-surge,theRN whotakesthemmust decreasetheirworkload (i.e. reduce PTload ifthey

take aDTPT)->Hint:on boards, the setting is

always perfect (i.e. enough staff/time/resources on the unit etc.) DRUGS

AMINOGLYCOCIDES

• powerful class ofantibiotics(when nothing else works pull these outs, the big guns)

• don’t use unless anything else works

•boards love to test these drugs because they’re dangerous and are a test of safety

• think:A MEAN OLD MYCIN

->a mean old= they treat serious, life-threatening, resistant, Gram-neg bacteria infections (i.e.a mean oldantibiotic fora mean oldinfection) ->mycin= what they end with (allend w/ -mycin)** not all -mycin’s are aminoglycosides BUT most are (the 3 that are not are erythromycin, azithromycin, clarithromycin =throw it off the list!)

•2 toxic effects:

• when you see ‘-mycin’, thinkmice

-mice->ears->otto toxic

• monitor hearing, tinnitus, vertigo/dizziness ii) the

humanear is shaped like akidneyso next effect isnephrotoxicity

• monitorcreatinine(not BUN, output, daily

weight) *creatinine= the best indicator of kidney/renal function(pick 24 hr. creatinine clearance over serum creatinine if both available) •#8 (fits nicely in the kidney) reminds you about 2 things about these drugs

• toxic to cranial nerve 8 = ear nerve
• administer Q8

•route:

• IM or IV

•do not give PO -> they are not absorbed- if you give an oral ‘-mycin’ it will go into gut, dissolve, go through and come out as expensive stool (won’t have any systemic effect)

-EXCEPT in 2 cases=bowel sterilizers:

*hepatic encephalopathy (hepatic coma)= to get ammonia down, oral ‘-mycin’s’ will sterilize the bowel by killing Gram-neg bacteria (E. coli) to help bring down ammonia and won’t harm the damaged liver because it doesn’t go through the liver (also gives diarrhea, more poop out is good) *pre-op bowel surgery= it sterilizes the gut by killing the E. coli bacteria -if oral, no otto or nephro toxicity because not absorbed- these areneomycin&kanamycin

• Who can sterilize my bowels? NEO KAN

•Trough and Peak levels:

-trough= drug atlowest -peak= drug athighest ** TAP levels -trough administer peak -> draw trough levels first -> administer your drug -> draw peak levels after drug administration •Why draw levels?=narrow therapeutic window-