Mark Klemik Lecture 1: Acid Base Principles

Mark Klemik Lecture 1: Acid Base Principles

 As the ph goes, so goes my pt (except for k+)  When ph goes up, systems in the body get irritable/hyper-excitable, borborygmi*  When ph goes down, systems in the body shut down  MacKussmauls. You see Kussmauls with metabolic acidosis  There’s a difference between s/s of acid base imbalances vs. causes of acid base imbalances

 Cause: Ask yourself is it lung? Then it's respiratory

 Is the pt over ventilating or under ventilating? For Over- pick alkalosis  Under- pick acidosis  Ventilation means gas exchange. Resp. rate doesn't matter. Sao2 matters. It's not lung? Then it's metabolic.

 ** Only 1 scenario for Metabolic alkalosis:

If pt has prolonged vomiting or suctioning  For everything else that isn't lung, pick metabolic acidosis  Idk what to pick- Metabolic acidosis  Modifying phrase trumps original noun. “An ocd pt who is now psychotic” (look @ psychotic). “A vomiting pt who is now dehydrated” (look @ dehydrated).

Vent Alarms

 High pressure alarm goes off: working too hard (obstruction)

• Check for kinks, unkink
• Water condensation in the tube, empty it

3. Mucus in the airway: turn/cough/deep breathe,

• If that doesn't work then suction (last resort)

 Low pressure alarm goes off: that was too easy (disconnection)

a. Main tubing: reconnect

b. O2 sensor tubing (senses fio2 @ trachea area): reconnect

 Translate respiratory alkalosis to ventilating over (settings are too high)  Respiratory acidosis to ventilating under (settings are too low)

Mark Klemik Lecture 2: Alcohol/Drugs

 Denial is the #1 problem in all abusive situations

 Alcoholism: #1 problem psychologically is denial.

 Treat it by confronting it. Point out the difference from what they say and what they do. With abuse you confront, with loss you support.

 Dependency: the abuser gets to keep using

 Codependency: the significant other feels positive self esteem from

supporting the habit  Set limits & enforce them, teach them to say no. “I'm saying no because I'm a good person.”  Manipulation: Abuser gets significant other to do things for him/her that's not in the best interest for the significant other. The nature of the act is dangerous or harmful. Set limits & enforce them, teach them to say no. Manipulation is easier to treat than dependency because there's no positive self esteem issue with manipulation.

 Neutral: dependency/codependency has 2 pts.

 Negative: manipulation has 1 pt.

Wernicke Korsakoff- Psychosis induced by Vitamin B1 or Thiamine

 S/s: Amnesia with confabulation (memory loss with making up stories)

 Don't confront them or present reality. Redirect them.

 To prevent/stop it from getting worse: Take vitamin B1.

 They don't have to stop drinking, and it’s irreversible.

Aversion Therapy: Antabuse (disufiram) & ReVia (naltrexone)

 Makes you hate alcohol and if you drink it you’ll get deathly ill  Takes 2 weeks to get into the system  Need 2 weeks to get out of system to safely drink again

 Teach pt to avoid all alcohol products:

• Mouthwash
• Aftershave
• Perfumes/Cologne
• Insect repellent
• Anything that ends in elixir
• Alcohol based hand sanitizer
• Unbaked icing (vanilla extract)

**They can have red wine vinegarette!Every abused drug is either an upper or downer.

The most abused drug that isn’t up or down is a laxative.

Uppers (5):

 Caffeine, Cocaine, PCP/LSD (hallucinogens), Methamphetamines, Adderral

 S/s: (Things go up) euphoria, tachycardia, tachypnea, restlessness,

irritability, borborygmi/diarrhea, reflexes +3/+4 (spastic), seizure

Downers:

 Heroin, Marijuana, Alcohol, Benzos (everything not an upper)

 S/s: Lethargy, respiratory depression, bradycardia, bradypnea,

How to answer the question:

 Ask yourself: Is the drug an upper or downer?

 Is the question asking about overdose or withdrawal?

 Withdrawal in upper: everything goes down

 Withdrawal in downer: everything goes up

 Resp. depression biggest risk in: downer overdose and upper withdrawal

Drug Addiction in Newborns  Always assume intoxication, not withdrawal at birth  Baby has to be 24hrs old to go through withdrawal  Withdrawal: difficult to console, exaggerated startle reflex, seizure risk, shrill high pitch cry

Alcohol Withdrawal Syndrome vs Delirium Tremens  Every alcoholic goes through withdrawal, **only a small amount get delirium tremens**. You go into alcohol withdrawal within 24 hrs. You go into delirium tremens within 72 hrs. AWS pts are not life threatening, DT’s can kill you  Pts with AWS not a danger to self or others, DT’s are dangerous to self and others.

ALCOHOL WITHDRAWAL:

 Regular diet, semi-private room anywhere on unit, up adlib (go anywhere they want), no restraints.

 Meds: Antihypertensive pill, Tranquilizer, Vitamin B1

DELIRIUM TREMENS:

 NPO/clear liquids (seizure risk), private room, near nurses station, strict best

rest / need bed pans & urinals, must be restrained appropriately: vest or 2

point locked leathers (opposite arm & leg) rotate every 2 hours.

 Meds: antihypertensive pill, tranquilizer, b1 vitamin

Aminoglycocides- A Powerful Class of Antibiotics  A mean old mycin for a mean old infection  Life threatening, resistant, serious, and gram negative infections  All end in mycin, but not all that end in mycin are mean old mycins

 NOT MeanOldMycins: Arithromycin, Zythromycin, and Clarithromycin.

 If it has thro, throw it off the list!! They are ototoxic (ear toxic) mycin (mice- ears)  Monitor for hearing, tinnitus, vertigo/dizziness  The human ear is shaped like the kidney, so watch for nephrotoxicity  Best indicator of liver funct: 24hr creatinine clearance** #2 serum creatinine

 Administer them q8hr. Route: IM or IV. Don’t give PO for infection!

 Only 2 cases to give orally: sterilize the bowel

• Hepatic encephalopathy/hepatic coma/liver coma

(when ammonia level gets too high & gets to your brain) Kills the E. coli in the gut & lower the ammonia level

• Pre-op bowel surgery to sterilize the bowel

Oral mycins will kill gram-negative bacteria in your gut (sterilize bowel)

 Sargent asks: Who can sterilize my bowel?

Neo can! NEOMYCIN and CANOMYCIN!

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TAP Levels:

 Trough- When drug is at its lowest (Draw before drug admin)  Peak- When drug is at its highest (Draw after drug admin)  TAP (trough, administer drug, peak) for narrow therapeutic windows

 THE DRUG DOESN’T MATTER, THE ROUTE MATTERS ;)

 Sublingual/IV/IM/SQ/PO Trough: Draw 30 mins before the next dose

 Sublingual Peak: 5-10 mins after drug is dissolved

 IV Peak: 15-30 mins after drug is finished

 IM Peak: 30-60 mins

 SQ- See diabetes lecture  PO- They don’t test PO peaks  When there’s 2 right answers, pick the highest without going over

Mark Klemik Lecture 3- Cardiac/Chest Tubes/Infection Precautions  CCB’s are like Valium for your heart (calms your heart down)