MARK KLIMEKS LECTURE 1 12 STUDY GUIDE

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MARK KLIMEK’S LECTURE 1 – 12 STUDY GUIDE

ALL ANSWERED

Lecture 1— Acid-Base Balance Dumping/HH

Ventilators Electrolytes: K+, CA, MG,

and NA Lecture 2— Alcohol TX for HyperKalemia Wernicke Overdose and Withdrawal Lecture 7— Thyroid (Hyper-, Hypo-) S/Sx Adrenal Cortex (Addison Aminoglycosides Disease, Cushing) Peak and Trough Toys Laminectomy Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Lecture 8— Lab Values Aminophylline) Five Deadly Ds Kernicterus Neutropenic Precaution Dumping/HH

Electrolytes: K+, CA, MG, Lecture 9— Psych Drugs

and NA Tri TX for HyperKalemia Benzo MAOI Lecture 4— Crutches Lithium Canes Prozac Walkers Haldol Delusions Clozaril Hallucinations Zoloft Psychosis Psychotic and Non-Psychotic Lecture 10— Maternity and Neonatology Hallucination Illusion Lecture 11— Fetal Complications Delusion Stages of Labor Assessments Lecture 5— Diabetes Mellitus Variations for NB Diabetes Insipidus Maternity Meds SIADH Medication Hints Insulin Psych Tips DKA Operational Stages HHNK Lecture 12— Prioritization Lecture 6— Drug Toxicities (Lithium, Delegation Lanoxin, Dilantin, Bilirubin, Staff Management Aminophylline) Guessing Strategies Kernicterus

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Acid/Base Balance (Start times: 30:00)

In order to solve acid-base disorders, it is important to know the normal values for pH, CO2 and HCO3 (bicarbonate), which are shown below • pH 7.35 to 7.45 • CO2 35 to 45 • HCO3 22 to 26

The first value to look at in an acid-base disorder is the pH • If pH is <7.35, the acid-base imbalance is acidotic • If pH is <7.45, the acid-base imbalance is alkalotic

Now, to determine if the imbalance is metabolic or respiratory, determine whether HCO3 goes in the same or opposite direction with pH • Rule of the Bs: If pH and Bicarb move both in the same direction, then the acid-base imbalance is metabolic … Otherwise, it is respiratory

Example #1 • pH 7.3 Acidotic • HCO3 20 Metabolic • This is an example of metabolic acidosis

Example #2 • pH 7.58 Alkalotic • HCO3 32 Metabolic • This is an example of metabolic alkalosis

Example #3 • pH 7.22 Acidosis • HCO3 35 Respiratory • This is an example of respiratory acidosis

As the pH goes, so goes my patient, except for Potassium … That means • If pH is low, everything is low, except potassium • If pH is high, everything is high, except potassium

Lecture 1 • Mark Klimek • 92:21

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If pH goes over 7.45, this is alkalosis • Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi (increase bowel sounds), hyperreflexia (3+, 4+) • However, potassium is opposite. Therefore, hypokalemia • What is the nursing intervention?

• Pt need suctioning because of seizures

If pH goes below 7.35, this is acidosis • Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma hyporeflexia (0, 1+), bradypnea, low BP • However, potassium is high (hyperkalemia) • What is the nursing intervention?

• Pt needs to be ventilated with an Ambu bag—respiratory arrest

So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause Metabolic ACidosis with Kussmaul respirations

Causes of Acid/Base imbalance

First ask yourself, “Is it LUNG? … If yes, then it is respiratory • Then ask yourself, “Are they overventilating or underventilating?

• If UNDERventilating, then pick acidosis—pH is under 7.35
• If OVERventilating, then it is alkalosis, pH is over 7.45

What type of acid-base derangement is present in the following condition?• In labor?

• Respiratory alkalosis … Overventilating—pH increases … Alkalosis)

• Drowning?

• Respiratory acidosis … Underventilating—pH decreases … Acidosis

• Pt is on PCA (patient-controlled anesthesia) pump?

• Ventilation is down … Respiratory acidosis

If it is not LUNG, then it is metabolic. If the patient has prolonged gastric vomiting or suction (sucking out acid), pick alkalosis • For everything else that isn’t lung, pick metabolic acidosis • So, when you don’t know what to pick, pick metabolic acidosis

Tip • Set your default setting to Metabolic Acidosis • Always pay attention to modifying phrase rather than original noun

Figure 1. Patient- controlled anesthesia (PCA) pump.

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Ventilator

A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is equipped with a high and a low-pressure alarm

High pressures alarms are always triggered by increased resistance to air flow. Look for obstructions, i.e., • Kinks in tubing …

Solution: unkink the tube

• Condensed water in the dependent tube …

Solution: empty it

• Mucus plugs … Solution:

Ask pt to turn, cough, deep breathe; or suction the tubing PRN

What is the appropriate order to address high pressure alarm in a mechanical ventilator?• (1) Unkink. (2) Empty water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) suction

Low pressures alarms are always triggered by decrease in resistance. This can be caused by • Main tubing disconnection • O2 sensor tube disconnection • In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call Respiratory Therapist

The ventilator may be set too high or too low • Setting is too high … Pt is overventilated

• Respiratory Alkalosis … Panting

• Setting is too low … Pt is underventilated

• Respiratory Acidosis … Pt is retaining CO2

Question The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory acidosis. What would you do next?• Notify the physician that the pt is not ready to be weaned off the respirator

• Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready

to be weaned off the ventilator

• If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off