Mark Klemik Lecture 1: Acid Base Principles

Mark Klemik Lecture 1: Acid Base Principles

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

base imbalances G Cause: Ask yourself is it lung? Then it's respiratory G Is

the pt over ventilating or under ventilating? G For Over- pick alkalosis G Under- pick acidosis G Ventilation means gas exchange. G Resp. rate doesn't matter. Sao2 matters. G It's not lung? Then it's metabolic. G ** Only 1

scenario for Metabolic alkalosis: If pt has prolonged vomiting or suctioning

G For everything else that isn't lung, pick metabolic acidosis G Idk what to pick- Metabolic acidosis G 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

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

• Check for kinks, unkink 2. Water condensation in the tube, empty it 3.

Mucus in the airway: turn/cough/deep breathe, 4. If that doesn't work then

suction (last resort)

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

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

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

Mark Klemik Lecture 2: Alcohol/Drugs

G Denial is the #1 problem in all abusive situations G Alcoholism: #1 problem

psychologically is denial. G Treat it by confronting it. Point out the difference from what they say and what they do. G With abuse you confront, with loss you support. G Dependency: the abuser gets to keep using G Codependency: the significant other feels positive self esteem from supporting the habit G Set limits & enforce them, teach them to say no. “I'm saying no because I'm a good person.” G 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. G Set limits & enforce them, teach them to say no. G Manipulation is easier to treat than dependency because there's no positive

self esteem issue with manipulation. G Neutral: dependency/codependency

has 2 pts. G Negative: manipulation has 1 pt.

Wernicke Korsakoff- Psychosis induced by Vitamin B1 or Thiamine

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

Don't confront them or present reality. Redirect them. G To prevent/stop it

from getting worse: Take vitamin B1. G They don't have to stop drinking, and

it’s irreversible.

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

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

drink again G Teach pt to avoid all alcohol products:

• Mouthwash 2. Aftershave 3. Perfumes/Cologne 4. Insect repellent 5.

Anything that ends in elixir 6. Alcohol based hand sanitizer 7. 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):

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

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

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

Downers:

G Heroin, Marijuana, Alcohol, Benzos (everything not an upper) G S/s:

Lethargy, respiratory depression, bradycardia, bradypnea,

How to answer the question:

G Ask yourself: Is the drug an upper or downer? G Is the question asking

about overdose or withdrawal? G Withdrawal in upper: everything goes down

G Withdrawal in downer: everything goes up G Resp. depression biggest risk

in: downer overdose and upper withdrawal

Drug Addiction in Newborns G Always assume intoxication, not withdrawal at birth G Baby has to be 24hrs

old to go through withdrawal G Withdrawal: difficult to console, exaggerated

startle reflex, seizure risk, shrill

high pitch cry Alcohol Withdrawal Syndrome vs Delirium Tremens G 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. G AWS pts are not life threatening, DT’s can kill you G Pts with AWS not a danger to self or others, DT’s are dangerous to self and others.

ALCOHOL WITHDRAWAL:

G Regular diet, semi-private room anywhere on unit, up adlib (go anywhere

they want), no restraints. G Meds: Antihypertensive pill, Tranquilizer, Vitamin

B1

DELIRIUM TREMENS:

G 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. G Meds:

antihypertensive pill, tranquilizer, b1 vitamin Aminoglycocides- A Powerful Class of Antibiotics G A mean old mycin for a mean old infection G Life threatening, resistant, serious, and gram negative infections G All end in mycin, but not all that end

in mycin are mean old mycins G NOT MeanOldMycins: Arithromycin,

Zythromycin, and Clarithromycin. G If it has thro, throw it off the list!! G They are ototoxic (ear toxic) mycin (mice- ears) G Monitor for hearing, tinnitus, vertigo/dizziness G The human ear is shaped like the kidney, so watch for

nephrotoxicity G Best indicator of liver funct: 24hr creatinine clearance** #2

serum creatinine G Administer them q8hr. Route: IM or IV. Don’t give PO for

infection! G 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 2. Pre-op bowel surgery to sterilize the bowel Oral mycins will kill gram-negative bacteria in your gut (sterilize bowel) G

Sargent asks: Who can sterilize my bowel? Neo can! NEOMYCIN and

CANOMYCIN!

--

TAP Levels:

G Trough- When drug is at its lowest (Draw before drug admin) G Peak- When drug is at its highest (Draw after drug admin) G TAP (trough, administer

drug, peak) for narrow therapeutic windows G THE DRUG DOESN’T

MATTER, THE ROUTE MATTERS ;) G Sublingual/IV/IM/SQ/PO Trough:

Draw 30 mins before the next dose G Sublingual Peak: 5-10 mins after drug is

dissolved G IV Peak: 15-30 mins after drug is finished G IM Peak: 30-60 mins G SQ- See diabetes lecture G PO- They don’t test PO peaks G When there’s

• right answers, pick the highest without going over

Mark Klemik Lecture 3- Cardiac/Chest Tubes/Infection Precautions G CCB’s are like Valium for your heart (calms your heart down) G CCB’s are negative inotropics, negative dromotropics, and negative chromotropics. G Weaken, slow down, and depress the heart. Cardiac depressant.

They treat: A, A-A, and A-A-A

G Anti-hypertensive G Anti-angina G Anti-atrial-arrhythmia= it treats everything atrial related, EXCEPT supra ventricular tachycardia (supra means above, above the ventricle is the

atrial). G Side effects: Headache & hypotension

Names of CCB’s:

G Names ending in “dipine” (You're dipping in the calcium channel) G Verapamil G Cardizem = Continuous IV drip G Monitor BP intermittently. If systolic is below 100, hold.For drip, if systolic was 98 titrate it down.

Cardiac Arrhythmias:

G Normal sinus rhythm- Peaks of p waves are evenly spaced G V-fib- Chaotic squiggly line. No pattern G V-tach- Sharp peak & jags. There's a pattern G Asystole- Flat line G QRS depolarization- Answer will always be ventricular G P wave- Answer will always be atrial G Lack of a P wave- Answer will always be ventricular G A lack of QRS- Asystole G A-flutter- Saw tooth G Chaotic is always the word used to describe fibrillation G Bizarre is always the word used for tachycardia

Low Priority:

G Premature ventricular contraction (PVC) G A bunch of PVC’s is like a short

run of V-Tach Moderate Priority:

G If more than 6 PVC’s in a minute or row and/or if PVC falls on the T wave of the previous beat. They never are high priority!

Potentially Life Threatening:

G V-Tach- Pt has a pulse Lethal Priority: Kills you in 8 mins or less