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Mark Klimek Audio Tape 1
ACID BASE BALANCE
- Rule of B’s a. If the pH and the Bicarb are Both in the same direction, then it is meta bolic
- Signs and Symptoms a. As the pH goes, so goes my patient , except for potassium i. as pH goes up, systems gets irritable ii. as pH goes down, systems shut down
- UP pH (Alkalosis) a. HTN b. Tachycardia c. Tachypnea d. Seizures e. Irritability f. Spastic g. Diarrhea h. Borborygme i. Hyperreflexia, (3,4) j. Hypokalemia
- DOWN pH (Acidosis) a. Hypotension b. Bradycardia c. Constipation d. Absent bowel sounds e. Flaccid f. Bradypnea g. Hyperkalemia h. Lethargy i. Obtunded (one step down from lethargy) j. Paralytic ileus k. Coma l. Respiratory arrest b. MacKussmaul i. The only acid base to cause Kussmaul respirations is M etabolic Ac idosis 3. Causes a. First ask yourself, “Is it lung ?” If yes, then it’s respiratory. Then ask yourself: “Are they overventilating or underventilating. If overventilating , pick alkalosis. If underventilating , pick acidosis. b. If it is not lung, then it is metabolic. If the patient has prolonged gastric vomiting or suction, pick alkalosis. For everything else that
isn’t lung, pick metabolic acidosis. When you don’t know what to pick, choose metabolic acidosis.
VENTILATORS
- High pressure alarms are triggered by increased resistance to air flow.
- High pressure alarms are triggered by resistance to airflow and can be caused by obstructions of 3 types: kinked tube, (unkink) action, water in tube (empty) action, mucus in airway (turn, cough and deep breathe) action. Lastly suction
- Low pressure alarms are triggered by decrease resistance to airflow and can be caused by disconnections of the tubing (reconnect it) or oxygen sensor tube (reconnect it UNLESS tube is on the floor- bag them and call RT if this happens) (black coated wirey tubing that piggy backs the tubing, measure FiO2)
- Respiratory alkalosis means the ventilator settings may be too high.
- Respiratory acidosis means the ventilator settings may be too low.
- What does “wean” mean? Gradually decrease with the goal of getting off altogether
d. Disulfaram/Naltrexone (Antabuse/Revia) this medication makes the patient feel sick if drink, its aka Aversion Therapy. Patient will have a strong hatred for alcohol e. Onset and duration of effectiveness of Disulfaram (Antabuse/Revia): 2 weeks f. Patient teaching with Disulfaram (Antabuse/ Revia): Avoid all forms of alcohol to avoid nausea, vomiting, and death. g. What are examples of products that contain alcohol? Mouthwash, cologne, perfume, aftershave, all elixirs- most OTC liquid medicines, insect repellant, vanilla extract (un-cooked icings), hand sanitizer, vinaigrettes dressing, (the patient can have the Red wine vinaigrette dressing) h. Every alcoholic goes through alcohol withdrawal syndrome. Only a minority get Delirium Tremens. (Delirium Tremens can Kill you) i. Every abused drug is either upper or downer i. Uppers- caffeine, cocaine, PCP/LSD, methamphetamines (Treats ADHD), Adderall, Bath Salts….
- Signs and symptoms a. Euphoria b. Tachycardia c. Restlessness d. Irritability e. Increased bowels f. Hyperreflexia g. Spastic h. Seizure – have suction machine at the bedside ii. Downers- everything but uppers
- Signs and symptoms a. Drowsiness b. Lethargy c. Respiratory arrest j. Alcohol Withdrawal Syndrome is not life threatening. Delirium Tremens can kill you. k. Patients with Alcohol Withdrawal Syndrome are not a danger to themselves or others. Patients with Delirium Tremens are dangerous to self and others. OVERDOSE = TOO MUCH WITHDRAWL = TOO LITTLE l. Upper Overdose looks like downer withdrawal i. i.e. risk for seizure, need suctioning m. Downer OD looks like Upper withdrawal i. i.e. respiratory arrest/ depression n. DRUG ABUSE IN NEWBORN : Always assume intoxication not withdrawal at birth i. right after birth baby is intoxicated ii. 24 hours after birth, baby is in withdrawal
Alcohol Withdrawal Syndrome vs Delirium Tremens o. Alcohol Withdrawal Syndrome always precedes Delirium Tremens, however DT does not always follow AWS. i. AWS within 24 hours ii. DT after 72 hours Alcohol Withdrawal Syndrome Delirium Tremens Regular diet NPO/ Clear liquids Semi private, anywhere Private, near nurses station Up AD lib Bed rest, no bathroom privileges No restraints Restrained with vest or 2 point locked leather (1 arm, 1 leg) p. BOTH get i. Anti-HTN med ii. Tranquilizers iii. Multivitamin B
- Amnioglycosides a. For Amnioglycosides, think “ a mean old mycin ”. i. Mean old infection ii. Life threatening iii. Resistant iv. Gram negative b. Give IM or IV c. When are antibiotics/ aminoglycosides used? i. to treat serious, life-threatening, resistant infections d. All aminoglycosides end in mycin but not all drugs that end in mycin are aminoglycosides e. What are some examples of wannabe mycins? i. Azithromycin, Clarithromymicin, Erthromycin f. If it ends in mycin, it’s a mean old mycin but if it has thro in it, throw it away. g. What are some examples of aminoglycosides? i. Streptomycin, cleomycin, tobramycin, gentamycin, vancomycin, clindamycin h. When remembering toxic effects of mycin’s, think i. Mice= ears i. What is the toxic effect of aminoglycosides and what must you monitor? i. Ototoxicity, monitor hearing, balance, and tinnitus j. The human ear is shaped like a kidney so another toxic effect of aminoglycosides is nephrotoxicity so monitor creatinine k. The number 8 drawn inside the ear reminds you they are toxic to cranial nerve 8 and the frequency of administration is 8, q 8hours. l. Do not give aminoglycosides PO except in theses 2 cases
a. When bronchodilator doesn’t work give aminophylline then bronchodilator b. Therapeutic level (10-20) c. Toxic level = 20 and over
- PHENYTOIN (Dilantin)- seizures a. Therapeutic level (10-20) b. Toxic level = 20 and over
- BILIRUBIN in baby a. Therapeutic level (elevated level) (10-20) b. Toxic level = 20 and over c. Hospitalize at 14-
- Kernicterus- bilirubin in the brain CSF a. Often happens at 20 level
- Jaundice- yellow color d/t bilirubin in the skin
- Opisthotonos- position of slight extension in neck seen in pt with Kernicterus a. They hyperextend (BAD SIGN)
- In what position do you place an opisthotonos position? On their side
Dumping Syndrome vs. Hiatal Hernia
- Dumping Syndrome a. Post op gastric sx complication in which gastric contents dump too quickly into the duodenum b. Gastric contents move in the right direction at the wrong rate c. Speed issue d. Signs and Symptoms i. Drunk- cerebral impairment ii. Shock- vasomotor collapse, hypotension, tachycardia, pale, cold, clammy iii. Acute abdominal distress (cramping, N/V/D, hyperactive BS, guarding, tenderness, bloating, distension) e. Treatment- want to empty slower i. HOB- low position, flat, turn to side ii. Fluid- low fluid iii. Carbs- low carb, high protein f. Goal- get full stomach g. *when everything is low, the stomach goes slow
- Hiatal Hernia a. Regurgitation of acid into esophagus, because upper stomach herniates upward through the diaphragm b. Gastric contents move in the wrong direction at the right rate c. Direction issue d. Signs and Symptoms i. GERD if you lie down after you eat e. Treatment- want to empty faster i. HOB- high position ii. Fluid- high fluid
iii. Carbs- high carb, low protein f. Goal- get an empty stomach g. *in HIatal hernia, everything needs to be HIGH
- Drunk is drunk
- Shock is Shock
- Drunk + Shock = Hypoglycemia
- Drunk + Shock + Acute Abdominal Distress = Dumping Syndrome
Electrolytes
- Kalemias do the same as the prefix except for heart rate and urine output a. Hyperkalemia i. High symptoms ii. Except HR and Urine Output iii. Agitation, restlessness, tachypnea, tall T waves, ST elevated, diarrhea, hyper BS, spasticity, increased tone, hyperreflexia, LOW HR, LOW URINE OUTPUT b. Hypokalemia i. Low symptoms ii. Except HR and Urine Output iii. Lethargy, bradypnea, hypo BS, constipation, flaccidity, HIGH HR, HIGH URINE OUTPUT
- Calcemias do the opposite of the prefix. No exceptions. a. Hypercalcemia i. Everything goes low ii. 2 signs of neuromuscular irritability
- Ch vostek’s Sign= cheek tap facial spasm
- Trousseau’s Sign = BP cuff carpal spasm b. Hypocalcemia i. Everything goes high
- If symptom involves nerve or skeletal muscle, pick Calcium. For any other symptom, pick Potassium (generally anything effecting blood pressure )
- Magnesemias do the opposite of the prefix.
- When there is a tie, do not pick mag because its not a key player. Then think about if it is cardio or skeletal. Then rule out in that way.
- Hyp E rnatermia a. d E hydration- dry skin, thread pulse, rapid HR, hot i. DKA ii. HHAK
- Hyp O natermia a. O verload- crackles, overdistended neck veins i. SIADH ii. DI
- The earliest sign of any electrolyte disorder is numbness & tingling (paresthesias) a. Circumoral paresthesias – lip tingling
- The universal sign of electrolyte imbalance is muscle weakness (paresis)
h. Stairs: Which foot leads when going up and down stairs on crutches? i. Up with good , down with bad. The crutches always move with the bad leg. i. Cane: Hold the cane on the unaffected side. Advance cane with the opposite side for a wide base of support. j. What is the correct way to use a walker? Pick them up, set them down, walk to them k. If they must tie belongings to walker, tie to side not the front l. What is the correct way to get up from a chair using a walker? i. Hold on to chair, stand up, then grab walker.
Delusions, Hallucinations, and Illusions
- What is the difference between a non-psychotic person and a psychotic person? a. A non-psychotic person has insight (know they’re sick and that its messing them up) and is reality based (they see reality the same way as you) and a psychotic person has no insight and is not reality-based.
- Delusion- false fixed belief or idea or thought. There is no sensory component.
- What are the 3 types of delusion? a. Paranoid/Persecutory i. False fixed belief that ppl are out to harm you b. Grandiose i. false fixed belief that you are superior c. Somatic i. False fixed belief about a body part
- Hallucination- false fixed sensory experience a. Auditory- hear b. Tactile- feel c. Visual- see d. Gustatory- taste e. Olfactory- smelling
- Illusion- a misinterpretation of reality, sensory experience
- What is the difference between illusions and hallucinations? a. With illusions there is a referent in reality (something to which they can refer to)
- When dealing with a patient experiencing delusions, hallucinations, or illusions, first ask yourself? “What is their problem? (what are the different problems that could be going on?) a. Functional psychosis b. Psychosis of dementia c. Psychotic delirium
- What are the different types of functional psychosis? a. Schizophrenia, schzioaffeced (mood disorder though process), major depression, and mania b. (schizo, schizo, major, manic)
- With a functional psychosis the patient has the potential to learn reality. How can you teach reality to a functional psychotic? a. Acknowledge feelings b. Present reality i. Positive- what is reality ii. Negative- what is not reality c. Set a limit d. Enforce the limit
- Psychosis of dementia a. People with Alzheimer’s Wernicke’s, organic brain syndrome, and dementia. The patient has a brain destruction problem and cannot learn reality.
- How do you deal with a person with Psychosis of Dementia? a. Acknowledge feeling b. Redirect- get them to express the fixation that they are expressing inappropriately to appropriately
- Psychotic Delirium- temporary episodic secondary dramatic sudden onset of loss of reality due to chemical imbalance (UTI, thyroid imbalance, electrolyte imbalance)
- How do you deal with a patient with Psychotic Delirium? a. Acknowledge feeling b. Reassure them of safety and temporariness
- What are the different types of loosening of association? a. Flight of ideas, word salad, neologisms
- Flight of Ideas a. Stringing phases together (loosely associate phrases; tangentiality)
- Word salad a. Throw words together
- Neologisms a. Making up new words
- Narrowed self- concept a. When a PSYCHOTIC refuses to change their clothes or leave the room i. *don’t make a psychotic do something they don’t want to do
- Ideas of reference a. You think everyone is talking about you
- Dementia hallmarks a. Memory loss, inability to learn b. *functional can teach, dementias cannot
- Always acknowledge Feeling
- What are the 3 “Re’s”? a. Reassure b. Redirect c. Reality
b. N insulin NPH i. Onset 6 hour ii. *Peak 8- iii. Duration 12 hours iv. True intermediate acting v. Cloudy (suspension) vi. N- not so fast, not in the bag c. Humalog- Lispro i. Onset 15 min ii. peak 30 iii. Duration 3 hours iv. Fastest v. Give with meals not before d. Lantus – glargine i. Onset ii. Peak - none iii. Duration 12- iv. Long acting v. Only insulin u can give at bedtime e. Check expirations!! i. Opening vial of insulin date causes manufacture expiration dates
1. Only good 30 days after opening ii. Refrigerating at hospital is not necessary but pt should refrigerate at home. f. Exercise potentials insulin: if more exercise, need less insulin. If exercise, need more insulin g. Sick day rules for insulin (when sick your glucose goes up) i. Take insulin ii. Take sips of water iii. Stay active as possible h. Sick diabetes get hyperglycemia and dehydration i. Acute complications of DM i. Low blood glucose in DM I and DM II (insulin shock, insulin reaction, hypoglycemic shock, hypoglycemia) 1. Causes a. not enough food, *too much insulin or medication, too much exercise
- Signs and Symptoms a. Drunk + shock = hypoglycemia i. Cerebral impairment, vasomotor collapse, cold, clammy. Slow reaction time, labile. 3. Treatment a. Administer rapidly metabolizing carbohydrate (candy, honey, milk, juice)
b. *Ideal combination: sugar and protein/starch (OJ and crackers, apple juice and turkey, skim milk alone) c. If unconscious IV D10/D50, IM glucagon
4. Why is low blood sugar in DMI dangerous? a. It can cause permanent brain damage ii. High blood glucose in DM I (DKA/ Diabetic Ketoacidosis/ Diabetic Coma) 1. Only type one gets it (ketosis prone…. Duh) 2. Causes a. Too much food b. Not enough insulin c. Not enough exercise *d. acute viral upper respiratory infection within the last 10 days
- Signs and Symptoms DKA a. D ehydration (hot, flushed, dry) b. K etones in blood, Kussmaul breathing, high K+ c. A cidosis, Acetone breath, Anorexia 4. Treatment a. IV fluids at fast rate (200/hr) b. ® Insulin IV iii. High blood sugar in DM II (HHNK/ HHNC- hyperosmolar, hyperglycemic non-ketotic coma) 1. Severe dehydration, more life threatning 2. Causes
- Signs and Symptoms a. Dehydration (hot, flushed, dry) 4. Treatment a. Rehydrate 5. Long term complications a. Poor tissue perfusion (renal failure, cant heal well) b. Peripheral neuropathy (cant control bowel and bladder, cant feel feet) j. HgbA1C (glycosated hemoglobin) i. Best indicator of long term blood glucose control ii. 6 and lower k. Hot and dry, sugar high; Cold and clammy, need some candy
14. Post operation risks for total thyroidectomy in 12-48 hours a. Tetany r/t low calcium 15. Post operation risks for sub total thyroidectomy in 12-48 hours a. Thyroid storm 16. Hypothyroidism = hypo metabolism 17.NEVER PICK INFECTION WITHIN THE FIRST 72 hours 18. Symptoms of hypothyroidism a. Weight gain, hypotension, constipation, lethargy, cold intolerance, “slow” b. Do not sedate these patients! myxedema coma, (don’t give ambien before surgery) c. NEVER HOLD THYROID PILLS BEFORE SX UNLESS TOLD BY MD 19. Hypothyroidism is aka myxedema 20. What are the 3 reasons for accuchecks? a. DM, TPN, Steroids 21. Adrenal Cortex a. Conditions affected start with an A and a C i. Addison’s Disease 1. Under secretion of the adrenal cortex a. Hyper pigmented b. Do not adapt to stress well (JFK) hypoglycemia and hypotension (shock) ii. Treatments- steroids, add-a-sone 22. Cushing’s Syndrome is over secretion (cushy = more) of the adrenal cortex a. Signs and symptoms of cushings and steroids i. Cushman 1. Moonface, hirituism, water retention (hypernatremia and hypokalemia), gynecomastia, buffalo hump, central obesity, decreased bone density, easy bruising, irritability, immunosuppressed b. Treatment i. Adrenalectomy replacement therapy steroids
TOYS
- What are the 3 principles to consider when choosing appropriate toys for kids? a. Is it safe b. Is it age appropriate c. Is it feasible (can you actually do it? Specific to child’s situation)
- What are some safety considerations when it comes to kids toys? a. Size of toy (no small toys 4 kids under) b. No metal (dicasts) toys if O2 if is in use (spark things) c. Beware of fomites (non living objects that harbors microorganisms) – worst: plush toys/ stuffed animals; least- plastic toys that can be disinfected
- What is the best toy for 0-6 month olds ( sensorimotor )? a. Musical mobile 4. What is the 2nd^ best toy for 0-6 month olds (sensorimotor) a. Large and soft 5. What is the best toy for 6-9 months old (object permanence)? a. Cover/uncover toy (jack in the box) 6. What is the 2nd^ best toy for 6-9 months old (object permanence)? a. Firm but large (wood/ hard plastic allowed) b. *worst toy for them is musical mobile strangulation cause they can pull and sit up 7. What is the best toy for 9-12 months old? a. Verbal toy (tickle me elmo) 8. Remember with 9-12 months old purposeful activity with objects 9. Avoid answers with the following words in them for children 9 moths and younger: build, sort, stack, make, & construct 10.NEVER PICK AN ANSWER WITH THE FOLLOWING WORDS IN IT IF THE KID IS LESS THAN 9 MONTHS a. Build b. Sort c. Stack d. Make e. construct 11. What is the best toy for toddlers (1-3 years)? a. Push/ pull toy (wagon) 12. What skill is being worked on when toddlers play? a. Gross motor skill 13. What type of play do toddlers do? a. Parallel play (play alongside but not with) 14. What types of toys should be avoided with toddlers? a. Toys that require good finger control/ dexterity 15. Preschoolers need toys that work on a. Fine motor skills (fingers) and balance (dance, ice skating, and tumbling) 16. Preschoolers play is characterized by a. Cooperative play (play with each other) 17. Preschoolers like to play pretend 18. School age (7-11 years) aka concrete are characterized by the 3 C’s a. Created/ creative (give blank paper; get them involved) b. Competitive (winners and losers) c. Collective (baseball cards and Barbie’s) 19. Adolescents (12-18 years) their “play” is peer group association (hangout in groups). Allow adolescents to be in each other’s rooms unless one of them is: fresh post-op (less than 12 hours), immunosuppressed, contagious 20. When given a variety of ages to choose from always go younger because children regress when sick and you want to give them as much time to grow
a. Do not sit for longer than 30 mins b. Lie flat and log roll for 6 weeks c. Lifting restrictions: do not life more than 5 lbs (gallon of milk)
18. What are some permanent restrictions for laminectomy patients? a. Laminectomy patients will never be allowed to lift by bending at the waist (use their needs) i. Should instead lift with the knees b. Cervical laminectomy patients will never be allowed to lift objects above their heads c. No horseback riding, off trail biking, jerky amusement park rides, etc.
Mark Klimek Audio Tape 8
LAB VALUES
- Creatinine a. Best indicator of kidney function b. 0.6-1. c. level A unless getting a dye procedure
- INR a. Monitors Coumadin b. 2-3, increased INR= bleed risk c. >4 is critical i. hold all Coumadin ii. assess bleeding iii. prepare to give Vit K iv. call MD
- Potassium a. Can cause cardiac problems b. 3.5-5.0 (BOARDS- 3.5-5.3) c. what to do for low K i. critical ii. assess heart iii. prepare to give K iv. call MD d. what to do if K is 5.4-5. i. critical (high but still in the 5’s) ii. hold all potassium iii. assess heart iv. prepare kayexalate/D5W/Insulin
v. call MD e. what to do if K is > i. deadly dangerous ii. do all of the following at once
- hold potassium
- assess heart
- prepare kayexalate/D5W
- call MD
- STAY AT BEDSIDE
- DO WITH TEAM
- pH a. 7.35-7. b. what to do if pH is in the 6s? i. deadly dangerous ii. get vitals and call MD
- BUN a. 8-25(8 buns in a pack) b. what to do if elevated BUN i. check for dehydration
- Hgb a. 12-18 (teenage years) b. what to do if pt has a 8-11 hgb i. monitor patient ii. assess for bleeding or malnutrition c. what to do if < i. critical ii. assess for bleeding iii. prepare for transfusion iv. call MD
- HCO a. 22-26; abnormal but not worrisome
- CO a. 35- b. what to do if CO2 is in the 50s? i. critical (sign of respiratory insufficiency) ii. assess respirations iii. do pursed lip breathing (blow out candle and exhale for longer periods) iv. do not give O2 (it will increase CO2) v. this does not apply to COPD (this is their normal) c. What do you do if CO2 is in the 60’s i. Deadly dangerous ii. Sign of respiratory failure iii. Assess respirations iv. Do pursed lip breathing (to decrease anxiety but it wont really do anything)
