Exam (elaborations) Mark Klimek Lectures 1 to 12; The Guide Latest (Best,Graded A)

Mark Klimek Lectures 1 to 12; The Guide Latest (Best,Graded A) MARK KLIMEK Lectures 1 to 12: THE GUIDE LATEST 2021 (BEST GRADED A) Page 1 of 92 Lecture 1— Acid-Base Balance Ventilators Lecture 2— Alcohol Wernicke Overdose and Withdrawal S/Sx Aminoglycosides Peak and Trough Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 4— Crutches Canes Walkers Delusions Hallucinations Psychosis Psychotic and Non-Psychotic Hallucination Illusion Delusion Lecture 5— Diabetes Mellitus Diabetes Insipidus SIADH Insulin DKA HHNK Lecture 6— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 7— Thyroid (Hyper-, Hypo-) Adrenal Cortex (Addison Disease, Cushing) Toys Laminectomy Lecture 8— Lab Values Five Deadly Ds Neutropenic Precaution Lecture 9— Psych Drugs Tri Benzo MAOI Lithium Prozac Haldol Clozaril Zoloft Lecture 10— Maternity and Neonatology Lecture 11— Fetal Complications Stages of Labor Assessments Variations for NB Maternity Meds Medication Hints Psych Tips Operational Stages Lecture 12— Prioritization Delegation Staff Management Guessing Strategies GUIDE • Mark Klimek’s Lecture Page 3 of 92 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 Page 4 of 92 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? o 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? o 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? o If UNDERventilating, then pick acidosis—pH is under 7.35 o 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? o Respiratory alkalosis … Overventilating—pH increases … Alkalosis) • Drowning? o Respiratory acidosis … Underventilating—pH decreases … Acidosis • Pt is on PCA (patient-controlled anesthesia) pump? o 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. Patientcontrolled anesthesia (PCA) pump. Page 5 of 92 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 o Respiratory Alkalosis … Panting • Setting is too low … Pt is underventilated o 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 o Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready to be weaned off the ventilator o If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off Page 6 of 92 Alcoholism • The #1 psychological problem is DENIAL • How do you respond/treat to pts in denial? o Confront them by pointing out the difference b/w what they say and what they do o For instance, say something like: “Ok, you say you’re not an alcoholic but it is 10 a.m. and you’ve already had a 6 pack” … It is not the same as aggression. Don’t attack the person o Good answer has “I” … Bad answer has “YOU” o One place where denial is ok—loss and grief Stages of grief are “DABDA”—Denial, anger, bargaining, depression, acceptance o So when the question is about pt in denial, pay attention to whether you are dealing with loss or abusive situation Support = Loss Confront = Abuse Dependency vs. Co-dependency • The #2 psychological problem is Dependency or Co-Dependency • Dependency: when the get the significant other to do things or make decisions for them o The abuser is dependent • Co-dependency: when the significant other derive self-esteem for doing things or making decisions for the abuser o The significant other is the co-dependent • Dependency and co-dependency has a symbiotic, yet a pathological relationship o The dependent pt get a free ride on the co-dependent o The co-defendant pt feels good from “doing stuff” for the abuser • How do you treat dependency/codependency? o Dependent pts are “abusers” … Confront them o Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them o Agree in advance on what requests are allowed then enforce o Teach significant other to say no o Work on self-esteem on the co-dependent person Manipulation • Manipulation is when the abuser gets the significant other to do things or make decisions that are not in the best interests of the significant other o The nature of the act is dangerous and harmful to the significant other Lecture 2 • Mark Klimek • 101:54 The title of this section is alcoholism. However, this rule can be used for any abuse situation 1. So, what it the number 1 psychological problem in child abuse? … In gambling? … In cocaine abuse? … In spousal abuse? … In elder abuse? a. The answer is denial Page 7 of 92 • How is manipulation like dependency? o In both situations the dependent person gets the co-dependent person to do things or make decisions o If what the significant other is being asked to do is not inherently dangerous and harmful, then this is dependency/co-dependency o However, if the significant other is being asked to do something inherently dangerous and harmful, then this is manipulation • Manipulation? Set LIMITS and Enforce them Examples Determine if either one of these situations is dependent/co-dependent problem or a manipulation problem • A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her. o The mother is manipulating the son o This is an illegal act = Harmful o Dependency … There are 2 patients o The dependent has a denial issue o The co-dependent has a self-esteem issue • A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her. o This is not illegal for the husband to buy alcohol o This a dependency/co-dependency situation o Manipulation … There is 1 patient—no self-esteem issues o Easier to treat because no one like to be manipulated Wernicke (Korsakoff) Syndrome Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2 as 1 condition • Wernicke is an encephalopathy • Korsakoff is a psychosis • Wernicke and Korsafoff tend to go together Wernicke and Korsafoff • Psychosis induced by Vitamin B1, thiamine deficiency • This is a situation the pt looses touch with reality due to vit B1 deficiency • The primary S/Sx are amnesia (memory loss) and confabulation (making up stories) o Confabulation—The lies for this pts are just as real as reality How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a meeting with Barack Obama this morning? • Redirect the pt to something he can do o For instance, tell pt something along that line: “Why can we go watch TV to see what is on the news today” Page 8 of 92 Characteristics of Wernicke and Korsafoff syndrome 1. Preventable … Take B1 2. Arrestable (stop it from getting worse) … Take B1 3. Irreversible (70%) … Will kill brain cells Antabuse and Revia (Disulfiram) • Antabuse—Alcohol deterrent • Revia—Antidote • Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect o Works in theory better than in reality • Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness of Antabuse/Revia is 2 weeks o For instance, if pt will be at a function and would like to drink, the pt must be on Antabuse/Revia at least 2 weeks prior to the event • Patient teaching o Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even death o Teach them to avoid the followings items as they contain alcohol … Mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (can’t have cupcake with unbaked icing) o On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it Overdose and Withdrawal First thing you ask in an overdose question is: Is it an Upper or a Downer? • This is because every abuse drug is either an Upper or a Downer • However, laxative abuse in the elderly is neither an Upper nor a Downer Upper Downer • Caffeine • Cocaine • PCP/LSD (psychedelics/hallucinogens) • Methamphetamines • Adderall • Memorize these five for the NCLEX • There are over 135 drugs that are downers • If it is not an upper, it is a downer Signs and Symptoms • Things go UP! • Euphoria, seizures, restlessness, irritability, hyperreflexia (3+, 4+), tachycardia, increased bowels (borborygmi), diarrhea Signs and Symptoms • Things go DOWN! • Lethargic, respiratory depression/arrest, constipated, etc. Page 9 of 92 What are the highest nursing priority to anticipate in an Upper or Downer? • Upper: The highest priority to anticipate in an Upper is suctioning due to seizures • Downer: The highest priority to anticipate in a Downer is intubation/ventilation due to respiratory arrest Example One of your pt is “high on cocaine.” What is critically important to assess? • Having a RR of 12 is not a critical measurement to assess for that pt • However, assessing for reflexes (3+ or 4+), irritability, borborygmi (increased bowel sounds), or increased temperature would be more appropriate o The “ABC rule” does not apply here … In fact, the pt’s ABC in cocaine toxicity is unremarkable After you know that the drug in question is an Upper or a Downer, the second question you should ask yourself is whether it is an Overdose or a Withdrawal • Overdose and withdrawal have the opposite effects Overdose Overdose on an Upper Overdose on a Downer • Too much • Too little Withdrawal Withdrawal on an Upper Withdrawal on a Downer • Too little • Too much Question The driver of a squad car calls the ER and says he is bringing a pt who in ODed on cocaine. What do you expect to see? … Select all that apply • Pt ODed on Upper OD … Expect to se Too much o First question: Upper or a Downer? o Second question: Overdose or Withdrawal? o S/Sx would be: Irritability, 4+ reflexes, borborygmi, increased temperature, etc. Question The same pt is withdrawing from cocaine … Same question • This pt is an Upper in Withdrawal = Too little • Therefore, respiratory is under 12, pt is difficult to arouse, give them Narcan Drug Abuse in the Newborn Always assume intoxication, not withdrawal at birth, in a newborn less than 24 hours after birth. 24 hours or more after birth, you can assume the newborn is in withdrawal Page 10 of 92 Question You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that apply • Overdose/withdrawal condition … Ask the following 2 questions o Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely a Downer) o Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal) o A Downer in Withdrawal = Too much o S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex Alcohol Withdrawal Syndrome vs. Delirium Tremens Alcohol Withdrawal Syndrome and Delirium Tremens are not the same • Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person stops drinking • However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium tremens … Delirium tremens occurs about 72 hours after the person stop drinking • Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens does not always follow alcohol withdrawal syndrome Alcohol Withdrawal Syndrome Delirium Tremens • Occurs after 24 hours after drinking • Non-life threatening to self and others • Occurs after 72 hours after drinking • Life threatening to self and others Nursing Care Plan