Mark Klimek Lecture Notes

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Mark Klimek Lecture Notes

LECTURE 1: Acid Base Principles & Ventilators

Interpreting blood gases (remember the rules of the B’s) ● If the pH and the bicarb are both in the same direction then it’s metaBolic (Bicarb Both Bolic), if they are in different directions then it is respiratory ● If bicarb is normal and the pH is low or high then its respiratory ● You will be given 8 values for arterial blood gas, always first look at the pH and the bicarb first ● You get acidosis and alkalosis from the pH

LABS: ABG’s

The normal pH is 7.35-7.45 The normal bicarb is 22-26 (the bicarb years where you make all the decisions [22-26 years old], or

2+2+2=6)

The normal CO2 is 35-45 (same as pH)

Signs and Symptoms with ABG’s ● As the pH goes up so does my patient

• If the pH goes up, every system in your body

gets more irritable/hyperexcitable ● As the pH goes down so does my patient

• If the pH goes down, systems in your body

shut down ● Except for potassium- When pH goes down, potassium goes up

● If the pH goes up (alkalosis): you will find

irritability, hyperreflexia (3&4), tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure (need suctioning at the bedside because they can seize and aspirate)

● If pH goes down (acidosis): hyporeflexia,

bradycardia, lethargy, obtunded, paralytic ileus, coma, respiratory arrest (need bag-mask ventilation bag at bedside for respiratory arrest), +1 reflexes

● MACkussmal- compensatory and respiratory

pattern for only acid base disorder: MAC- Metabolic

ACidosis

Respiratory Acidosis multiple choice example: What

would you see with a patient who is in respiratory acidosis?

• +1 reflex,
• diarrhea,
• adynamic ileus (no movement),
• spasm,
• urinary retention,
• paraxysmol atrial tachycardia,
• second degree lovitz, type 2 heart block (impulse

is being slowed),

• hypokalemia

LAB: REFLEXES

0&1-hyporeflexia 2-normal 3&4- hyperreflexia

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1) You notice a pt has ventricular fibrillation on the monitor (no cardiac output + no pulse) what is the first thing you are going to do?

a) Place a backboard

b) Begin chest compressions

This question is about order so you need to PLACE A BACKBOARD FIRST because it doesn’t make sense the other way around

If you get the same question with the word best you would pick BEGIN CHEST COMPRESSIONS-because it's technically the only thing you can do

2) What do you do if the chest tube gets pulled out?

a) First thing- take a gloved hand and cover

the hole

b) Best thing- cover with vaseline gauze

Where is it bubbling and when is it bubbling- ask yourself this question when you get bubbling questions

• Water seal- intermittent bubbling in the water

seal is GOOD (DOCUMENT IT)

• Water seal- continuous bubbling in the water

seal BAD- there is a leak the system and you need to find it and put tape over it until it stops leaking (LPNs can do this also)

• Suction control chamber- intermittent- BAD,

suction is not high enough in that case- need to go to the wall and turn up the dial in the wall so that it become continuous

• Suction control chamber – continuous- GOOD-

document it If something is sealed, should you have a continuous bubbling? NO because its leaking so intermittent is good and suction control is opposite of that

*** A straight catheter (in and out) is to a foley catheter (in, secure it, leave it) as a thoracentesis (in and out to reestablish negative pressure) is to a chest tube (stick it in, secure it, leave it)

RULES FOR CLAMPING TUBES

1) Never clamp a tube for longer than 15 seconds without a dr. order

-ex: if you break the water seal, you have 15 seconds

to cut it off and put tube under sterile water 2) Use rubber tipped double clamps- teeth need to be covered so that tube doesn’t get punctured and double because it’s best

CONGENITAL HEART DEFECTS

-Trouble or no trouble -Either it causes a lot of problems or its no big deal at all- no in between at all -GOOD or BAD TRouBLe – 7 letters – vowels lowercase Trouble defect- need surgery in order to live No trouble defect- don’t need surgery but might have it years later when it causes any trouble but we won't expect it to have any trouble because it's not trouble Trouble defect- ● Growth and development- DELAYED

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2) Nurse gets off at 7pm, gets home and eats dinner at

• and sits down and watches TV and continues

snacking and goes to bed and half hour later they have indigestion- HIATAL hernia because they laid down after they ate – dependent upon position and meal times

Signs and Symptoms of dumping syndrome: talk about

DRUNK- staggering gait, slurred speech, impaired judgment delay, labile emotions- because you have cerebral impairment because all of your blood is going to the gut because it dumped into the duodenum. Then you also get

signs of shock: hypotension, tachycardia, cold, clammy skin,

DRUNK + SHOCK=hypoglycemia. To get dumping syndrome, you get acute abdominal distress-signs and signs

and symptoms: cramping, pain, guarding, protecting, hear

borborygmi, diarrhea, bloating, distention, tenderness, all goes with dumping syndrome, learn them with drunk, shock and acute abdominal distress.

4 of the major things they stress:

Drunk=drunk Shock=shock Drunk + shock= hypoglycemia Drunk+shock+acute abdominal distress= dumping syndrome

To change the way the stomach empties, you can:

-play around with the head of the bed -play around with the water content of the meal -play around with the carbohydrate content of the meal

Treatment for hiatal hernia (hint: want stomach to empty

faster and why? If its empty it will not reflux) want to higher the head of the bed during and after meals to have gravity empty stomach faster, increase fluid content in meals so that it goes through stomach faster, carbs go through stomach very fast so up carbs **Hiatal hernia everything needs to be HIGH- head, fluids, carbs

Treatment for dumping syndrome (hint: want stomach

to empty slower) Lower head flat, turned to side and turning to the side with their head down, lower fluids with meals and only give fluids 1 hour 2 before or after meals, lower carb content to slow stomach emptying,

sLOWer: head low, fluid low, carbs low

CURVE question: protein in the diet? Low protein in hiatal

hernia, and high protein in dumping syndrome

Electrolytes:

To know your signs and symptoms of electrolytes you need

to memorize three sentences:

KALEMIAS: Potassium, do the SAME AS the prefix except

for heart rate and urine output Ex.Hyper vs. Hypo- HIGH with hyper, LOW with hypo because its doing the same as the prefix EXCEPT WITH HEART

RATE AND URINE OUTPUT

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● Fundal height- top part of the uterus- not palpable until week 12, cannot palpate during the first trimester

• When is the fundus at the belly button=20-22 weeks

of gestation ● That’s important for a nurse to know- because your dealing with date of viability ● Can you use fundal height to determine what trimester woman is in- good for when there is an emergency ● Mom is priority if she’s in the first trimester ● If your able to palpate the fundus that means she’s in the second trimester and she is still the priority ● If the fundus is above the umbilicus- she is in the third trimester- and the baby becomes the priority

Signs of Pregnancy ● Positive and everything else ● Fetal skeleton on x-ray ● Fetal presence on ultrasound ● Auscultation of a fetal heart rate of 140- it’s a baby- somewhere between 8 and 12 weeks it can actually be heard but it starts at week 5 ● “When would you first”, “when would you most likely”, “when should you by”- be careful reading OB questions

• ex. When would you first auscultate a fetal

heart- 8 weeks- beginning of range ● When would you most likely auscultate a fetal heart- 10 weeks- pick middle range ● When should you auscultate a fetal heart- 12 weeks- end of range ● When is quickening- when the baby kicks- 16-20 weeks, most likely- 18weeks, when should you- 20 weeks ● When the examiner palpates fetal movement- not when mom does

Maybe signs ● All urine and blood test are maybes (a positive pregnancy test is not a positive sign of pregnancy- its only probable- it only means you have the hormones increase with pregnancy ● Chadwick’s, goodell’s, hegar signs- occur in alphabetical order – weeks vary from woman to woman but the order does not vary ● -chadwicks- cervical color change to cyanosis- all start with the letter C ● goodell’s- cervical softening ● hegar’s- uterine softening

Patient teaching ● Teach woman the pattern of office visits to prevent mortality ● Once a month until week 28- ● Week 28- once every 2 weeks until week 36 ● Week 36- every week until delivery or until 42 weeks where you would schedule C sections ● Hemoglobin will fall and that’s normal- 12-16 is normal, but it can fall to 11 and be perfectly normal – not low but tolerable

● -2

nd trimester it can drop to 10.5 and be normal and in 3 rd it can drop to 10 and be normal