Mark Klimek Revised Notes. A+ Guide.ACID BASE BALANCE
RULE OF THE B’S
1. If the pH and the Bicarb are in the same direction METABOLIC
2. If the
... [Show More] pH and the Bicarb are in different directions RESPIRATORY
Examples:
pH 7.25 (v)
HCO3 20 (v)
Metabolic Acidosis
pH 7.21 (v)
HCO3 38 (^)
Respiratory Acidosis
pH 7.50 (^)
HCO3 30 (^)
Metabolic Alkalosis
pH 7.50 (^)
HCO3 25 (normal)
Respiratory Alkalosis (NORMAL)
SIGNS & SYMPTOMS
Know the principles, not the lists.
PRINCIPLE: “As the pH goes, so does my patient, except for potassium”
ALKALOSIS (^) ACIDOSIS (v)
Hyperreflexia Headache
Irritability Hyporeflexia
Tachypnea Bradycardia
Tachycardia Bradypnea
Borborygmi Paralytic/adynamic ileus
Seizures *need suction Coma
Hypokalemia Respiratory arrest *need ambu bag
HYPOkalemia MACkussmau’s (ONLY METABOLIC
ACIDOSIS “MAC”)
Heart block
HYPERkalmia
CAUSES OF IMBALANCES
OVER-VENTILATING UNDER-VENTILATING
RESPIRATORY ALKALOSIS RESPIRATORY ACIDOSIS
Examples:
- Pregnant woman hyperventilating.
- Ventilator setting is TOO HIGH.
Examples:
- Emphysema
- Drowning
- Pneumonia
- PCA pump (toxicity)
- Ventilator setting is TOO LOW.
2. What if it is NOT A LUNG SCENARIO? It is METABOLIC
PROLONGED SUCTIONING
OR VOMITING
ANYTHING ELSE!
METABOLIC Alkalosis METABOLIC Acidosis
Examples:
- Surgery with NG tube suction for
3 days
- Hyperemesis gravidum
Examples:
- Acute RF
- Infantile diarrhea
- 3
rd degree burns over 60% of body
- Hyperemesis gravidum
with dehydration
NOTE: Always pay attention to
MODIFYING PHRASE rather than
original statement.
.
1. Is it a LUNG SCENARIO? YES. It is RESPIRATORY.
VENTILATORS AND ALARMS
HIGH PRESSURE ALARM
Ventilator is working too hard to get air into lungs. There is INCREASED RESISTANCE due to
OBSTRUCTIONS.
1. Kinks unkink
2. Water condensing into dependent loops empty
3. Mucus in airway turn, cough and deep breathe, suction PRN.
LOW PRESSURE ALARM
Ventilator finds that it is working too easy to get air into lungs. There is DECREASED
RESISTANCE due to DISCONNECTIONS.
1. Main tubing is disconnected reconnect
2. Oxygen sensor tubing, which senses FiO2, is disconnected. This is the black
coated wire reconnect
Question
MD orders to disconnect ventilator in AM @ 0900hr. At 0600hr, ABC reveals respiratory
acidosis. What do you do?
a. Follow order
b. Call MD and hold order
c. Call RT
d. Begin to decrease settings.
B is the answer because the patient is not able to breathe without the ventilator. The settings
are TOO low. Patient should be in respiratory ALKALOSIS.
ALCOHOLISM
#1 PROBLEM: DENIAL
Psychological problem in abuse is denial, which is refusal to accept the reality of a problem.
Denial is the #1 problem in all abuse situations.
It is #1 because how can you treat someone who can’t admit that they have a problem?
You treat denial by confronting it by pointing out the difference between what they say and
what they do.
Confrontation attacks the problem. Aggression attacks the person.
You say you’re not an alcohol, but it’s 10AM and you already drank a 6-pack.
You say you’re not a spouse abuser, but she has a restraining order against you.
They deny, you confront.
Denial of loss + grief is different.
Stages of Grief: DABDA: Denial, anger, bargaining, depression, and acceptance
You want to support this type of denial.
Guy lost one hand and wants to play piano. You do not tell him he can’t. You ask him more
about piano.
Pay attention to the question, is it loss or abuse?
With loss you support. With abuse you confront.
#2 PROBLEM: DEPENDENCY VERSUS CODEPENDENCY
Dependency: Abuser gets significant other to do things for them. The abuser is dependent on
others.
Call in sick for me. Go buy me this. Drop me off here.
Codependency: Significant other derives positive self-esteem from making decisions for or
doing things for the abuser.
Aren’t I such a great wife for calling in sick for you?
Abuser: Life without responsibility
Significant Other: Positive self esteem
Treatment:
Set limits and enforce them. Teach significant other to say NO.
Work on self-esteem of the codependent person to solve the issue.
o I’m saying no and I’m a good person because I’m saying no.
May solve the problem but may lose relationship.
#3 PROBLEM: MANIPULATION
Manipulation: Abuser gets significant other to do something that is not in the best interest of
significant other. Nature of act is dangerous or harmful.
How is manipulation like dependency?
In both situations, the abuser is getting them to do something for them.
The difference is neutral versus negative. Look at what they’re being asked to do.
If what the s/o is being asked to do is neutral = dependency/codependency.
A 49y/o alcoholic gets her 50y/o husband to go to the store to buy alcohol for her, because
this is legal.
Last week, your sister in law calls you and says, “Would you pick up little Billy from
basketball practice at school? So he can spend the night at your house b/c of the snow.”
You have a 4x4 Hummer and you live 3 blocks from the school, and you do it.
If what the s/o is being asked to do is harmful/dangerous to s/o = manipulation.
A 49y/o alcoholic gets her 17y/o daughter to go to the store and buy alcohol for her,
because this is illegal as she is under age.
What if your sister in law calls you and she has the 4x4 Hummer and she lives 3 blocks from
school and she asks you to pick up her son and you have a KIA that is breaking down and
you live 20 miles away. This is dangerous. She can do it herself more safely.
Treatment:
Set limits and enforce them. You say NO.
Easier to treat because nobody likes being manipulated.
No positive self-esteem issue with manipulation like there is
with codependency/dependency.
How many patients do you have with DENIAL? 1.
How many patients do you have with DEPENDENCY/CODEPENDENCY? 2.
How many patients do you have with MANIPULATION? 1.
WERNICKE-KORSAKOFF SYNDROME – encephalopathy psychosis
Psychosis induced by Vitamin B1/thiamine deficiency
Lose touch with reality
Psychotic people
Primary symptom: amnesia with confabulation (memory loss, making up stories) because
they forgot and they believe it
Memory loss is “what happened in the 1990’s?” not “I got drunk last night, what happened?”
so they make up stories of what they were doing in the 90’s
Treatment:
Do not present reality because they won’t learn it.
Redirect rechannel it into something they can do not telling them what they can’t do:
o Pt: “I’m going to presidential meeting at 8AM?”
o Well why don’t we take a shower then watch CNN and watch what’s going on in
Washington?
Characteristics:
Preventable take vitamin B1 which is a coenzyme needed for metabolism for alcohol; if
deficient, alcohol will be stored and ruin brain cells.
Arrestable They don’t have to stop drinking; they just have to take vitamin B1.
o Stop it from getting worse? Take vitamin B1
Irreversible 70% irreversible (on boards, answer with majority).
ANTABUSE ARABIA (DISULFIRAM)
Aversion therapy
Aversion: Really strong hatred for something; gut hatred for something; we want alcoholics
to really hate alcohol
Works in theory better than in real life
Onset and Duration: Two weeks before effectiveness and two weeks off drug until they can
drink again
Patient Teaching
Avoid all forms of alcohol to avoid nausea, vomiting, death including:
Mouthwash even if they swish and spit
Aftershaves even if they put it on topically b/c causes nausea
Perfumes and colognes for the same reason
Insect repellants
Any OTC that ends in –elixir
Alcohol based hand sanitizers
Uncooked icings because they have vanilla extract
They CAN have red wine vinaigrette [Show Less]