Biological Principles Review - Nclex

KEEP CALM and PASS NCLEX with MARK KLIMEK Review 1. Acid-base balance/ventilators Rule of the B’s.. If the pH & the bicarb are both in the same direction = metabolic If they are in different directions = respiratory pH = 7.35-7.45 acidosis/alkalosis HCO3 (bicarb) = 22-26 (2+2+2 = 6) CO2 = 45-35 ex: pH: 7.30 = bicarb: 20 = = metabolic acidosis ex: pH: 7.58 = bicarb: 32 = = metabolic alkalosis ex: pH: 7.22 = bicarb: 30 = = respiratory acidosis ex: You are providing care to a client with the following blood gas results: pH 7.32, CO2 49, HCO3 29, PO2 80 & SaO2 90%. Based on the results, the client is experiencing: = acidosis, = respiratory -opioid: CNS depressant.. know the symptoms (sedation, respiratory depression, etc).. *principle: acid base signs/symptoms.. as the pH goes… so goes my patient!!! -when pH goes up; patient goes up.. (everything gets irritable!) -when pH goes down; patient goes down! (systems in your body shut down) …except with potassium: when pH goes up; potassium goes down… when pH goes down; potassium goes up! (up) alkalosis: irritibility, hyper-reflexia (3 & 4), tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure, aspirate.. (down) acidosis: hypo-reflexia, bradycardia, lethergy (obtunded), paralytic ileus (decreased bowel sounds), coma, respiratory arrest (ambu-bag!!) Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure… MAC Kussmaul!! M: metabolic AC: acidosis ex: pT has respiratory acidosis… (select all that apply).. +1 reflexes diarhhea adynamic ileus spasm urinary retention tachycardia 2nd degree mobits type 2 heart block hypokalemia SATA questions: *never only 1… never all of them* diarhhea will cause a metabolic acidosis.. but once you get acidodic, it will shut your bowels down = paralytic ileus …with scenarios.. always ask first “is it lung?” = respiratory …then ask if the pt is over-ventilating or under-ventilating? over-ventilating = alkalosis under-ventilating = acidosis …it’s about the SaO2!!! (pay attention!!) if it isn’t lung = metabolic.. if pt has prolonged gastric vomiting or suctioning… it’s always metabolic alkalosis… why? losing acid = becomes basic.. for everything else that is not lung - choose metabolic acidosis.. -if you don’t know the answer… always answer metabolic acidosis.. ventilators alarms.. high pressure alarm… triggered by increasure resistance to air flow.. (machine is pushing too hard to get air into the lungs).. respiratory alkalosis 3 obstructions: kink in tubing (get kink out), water condensing within the tube (empty tube), mucus secretions in the airway (turn, cough, deep breathe… then suction).. suction as needed!! *in that order*… low pressure alarm.. decreased resistance (too easy for the machine..) respiratory acidosis Low pressure alarms are triggered by decreased resistance to airflow & can be caused by disconnections of the main tubing or oxygen sensor tubing… Tubing (reconnect it!) - oxygen sensor tube (reconnect it UNLESS tube is on t the floor - bag them & call Respiratory therapist if this happens) Respiratory alkalosis = ventilator setting may be too high. Respiratory acidosis = ventilator setting may be too low. What does “wean” mean? gradually decrease with the goal of getting off altogether ex: Doc says wean off vent in AM… 6am ABG’s show resp. acidosis… a) follow order b) call respiratory c) hold order.. call doc d) begin to decrease the settings MASLOW’s Priorities (HIGHest - LOWest) physiological safety comfort psychological (problems within the person) social (problems with other people) spiritual ex: Arrange from HIGHest - LOWest… denial, spiritual distress, pain in elbow, fall risk, pathological family dynamics & electrolyte imbalance… = electrolyte imbalance (psyiological), fall risk (safety), pain in elbow (comfort), denial (psychological), pathological family dynamics (social) & spiritual distress (spiritual) 2. alcoholism.. (or any abuse) #1 problem = denial *refusal to accept the reality of a problem* You treat denial by confronting it… pronouns ~ good: i… bad: you… positions ~ good: i’m having a difficult time reading this… bad: you wrote it wrong.. loss & grief: Denial Anger Bargining Depression Acceptance don’t confront it; support it.. ex: You have a pt that just hand a hand amputated & they say, “I can’t wait to get back to playing the piano”… You say “Oh, how long have you played, etc? - you NEVER say “You can’t because you only have 1 hand” abuse = confront loss = support #2 problem = dependency *when the abuser get the significant other to do something.. “Call my boss, i’m sick”* (abuser gets to keep abusing..) = co-dependency *calls the boss*… (positive self esteem) How to treat this?!? Set limits and enforce them… Learn to say NO! manipulation = when the abuser gets the significant other to do things for him or her… the nature of the act is dangerous or harmful how is it like dependency? the abuser is getting the other person to do something no harm = dependent / co-dependent (wife buying alcohol for husband) dangerous/harmful = manipulated (kid buying alcohol for father) …depends on legal/illegal…………. Wernicke-Korsakoff Syndrome (WKS) is a neurological disorder. Wernicke's Encephalopathy and Korsakoff's Psychosis are the acute and chronic phases, respectively, of the same disease. WKS is caused by a deficiency in the B1 vitamin thiamine. Thiamine (B1) plays a role in metabolizing glucose to produce energy for the brain. primary symptom of WKS = amnesia with confabulation (making up stories) *they believe the lie..* ex: You have a pt who believes he is Ronald Regan’s Natioal Security Officer… And they want to go to a cabinet meeting… :/ WHAT DO YOU DO?!? Redirect!! (“well, why don’t you get a shower and then we’ll go watch CNN and see what the news is in Washington D.C.”) WKS is… -It’s preventable & arrestable (stop it from getting worse) - Take vitamin B1 -Irreversible… *About 70%* Antibuse (disulfiram) -alcoholism medication *aversion therapy!* It can treat problem drinking by creating an unpleasant reaction to alcohol. It's used in recovery programs that include medical supervision and counseling. How long does it take to get into & out of their system… 2 weeks Patient teaching - teach how to avoid NAUSEA, VOMITING & DEATH NO: mouthwash, aftershaves, perfumes/colognes, insect repellants, -elixer (Robitussin), alcohol-based hand santizers, un-cooked icings (vanilla extract)… However, they CAN have RED WINE VINAGERETTE! Overdoses/Withdrawals… Every abused drug is either an upper or a downer… *Laxative (not upper or downer) but can be abused by the elderly.. UPPERS: caffiene, cocaine, PCP/LSD, methaphetamines, adderall.. Signs/symptoms: things go up… euphoria, tachycardia, restlessness, irritibility, diarhhea, reflex 3/4, spastic - suction!!! DOWNERS: heroin, alcohol, marijuana, etc. Sign/symptoms: things go ambubag!!! ~ lethargic, respiratory depression, bradycardia, reflex 1/2, - 2 steps… Step 1: ask yourself, is it an Upper or Downer Step 2: ask yourself, is it an Overdose (too much) or Withdrawal (not enough) If they say: “overdosed on an upper” (too much upper)… pick things!! If they say: “downer & intoxication” (too much DOWNER)… pick things!! If they say: “withdrawal downer” (don’t have enough downer; too little!) Too little downer makes everything go up.. Too little upper makes everything go down.. Upper overdose LOOKS LIKE downer withdrawal… Downer overdose LOOKS LIKE upper withdrawal… 2 situtions (highest priority) = Respiratory depression/arrest: Downer overdose/upper withdrawal.. Seizure: Upper overdose/downer withdrawal… ex: Overdose on cocaine: UPPER/OVERDOSE.. (too much UPPER) *aka everything goes * What would you expect to see? (select all that apply) -irritability, reflex 3/4, increased temp, borborygmi (increased bowel sounds) Withdrawing from cocaine.. -Make sure the RR is above 12! Need NARCAN!!! Drug addiction in the NEWBORN ! Always assume intoxication, not withdrawal at birth …After 24 hours - it’s in withdrawal.. You are caring for an infant born to a equaline (pain killer) addicted mother… It is 24 hours after the birth… What do you expect to see.. SELECT ALL THAT APPLY: difficult to console, low core body temp, exaggerated startle reflex, respiratory depression, seizure risk, shrill high pitch cry… alcohol withdrawls = 24 (stable; not life threatening) *AWS* delirium tremens = 72 hours (unstable; can kill you) *DTS* AWS: regular diet, semi-private anywhere, up ad lib, no restraints.. DTS: NPO/clear liquid (seizure), private/near nurse’s station, restricted bed rest (bed pans/urinals), restrained (VEST or 2 point locked leathers *1 arm & opposite leg*)… AWS & DTS get a anti-hypertensive (BP pill) - everything is going up - keep everything down… They both get a tranquilizer, because their up… multivitamin *b1* to prevent WKS. DRUGS: aminoglycocides - powerful antibiotics (the BIG GUNS!!!) think: a mean old mycin = serious, life threatening, resistent, gram negative (TB, etc.)… if it ends in mycin = mean old mycin *not mean old mycins: erythromycin, zithromycin, clarithromycin (thro) if it has thro = throw it off the list… toxic effects: mycin = mice (ears)… oto-toxic!! -monitor hearing, tinnitus, vertigo (equalibrium) human ear shaped like kidney… nephro-toxicity! -monitor creatinine (best indicator for kidney function)… 8 (fits in a kidney) toxic to cranial #8 and you administer them Q8H… route: IM or IV.. do not give PO, because they are not absorbed.. ORAL mycins: hepatic coma (liver coma) amonia level gets too high.. pre-op bowel surgery (to clean the bowel)… #1 action: sterilize the bowel… which?! neomycin and canomycin… “Who can sterilize my bowel?! NEO KAN!!!” ☺ T: trough: when the drug is at its lowest… A: adminster P: peak: when the drug is at its highest… Why do we do a TAP?! (narrow therapeutic window) what works/what kills… Lasiks: 10-120 (wide) Dig: 0.125 - 0.25 (narrow) DO a TAP! IV push.. TROUGH: b4 sub: 30 mins.. b4 iv: 30 mins.. b4 IM: 30 mins… b4 subQ: 30 mins.. b4 PO: 30 mins.. PEAK: after sub: 5-10 mins.. after iv: 15-30 mins.. after IM: 30-60 mins… after subQ: SEE Diabetes lecture.. after PO: DON’T WORRY ABOUT IT.. 3. Calcium Channel Blockers: are like VALIUM for your !!! …calms you down.. calms the heart down! Tachy = yes shock = no negative inotropic, negative chronotropic, negative dromotropic = calm/relax… cardiac depressant -what do they treat: antihypertensives, anti-angina, anti-atrial-aarrhythmia, SVT (atrial) Side effects: HA, HTN Name: ends in -dapine… + Cardizem & Verapimil… Cardizem (can be continous IV) -Check BP: Hold CCB if SYSTOLIC is < 100! Cardiac Arrthymias - knowing how to read EKG strips… Know these 4 patterns!! 1) normal sinus rhythm 2) v-fib (no pattern) 3) v-tach (there’s a pattern) 4) asystole normal sinus rhythm a-fib a flutter v-fib v-tach asystole QRS de-polarization = ventricular P wave = atrial 6 rhythms… -a lack of QRS’s = asystole -saw tooth = a flutter -chaotic = atrial fibrilation -chaotic = ventricular fibrilation -QRS = ventricular tachycardia (bizzarre) -periodic bizarre wide QRS = PVC (low priority… can elevate to moderate: if there are more than 6/min.. or more than 6 PVC’s in a row.. or if the PVC falls on the T wave of the previous beat) PVC’s never reach HIGH.. LETHAL arrhytmias.. (they will kill you in 8 minutes or less) -asystole (HIGH) -v fib (HIGH) …have in common: NO cardiac output (pulse).. NO brain perfusion. *Potentially* LIFE threatening v-tach… (they have a cardiac output) TREATMENTS… PVCs/V-TACH: Ventricular… A (amioderone) Atrial: ABCD’s adenocard (adenosine); push in <8 seconds… *asystole for about 30 seconds!* beta blockers (side effects: HA/HTN) *no asthma!* calcium channel blockers… digitalis (digoxin, lanoxin) V-FIB: you D-FIB… Shock them! Asystole: EPI & atropine.. CHEST TUBES -purpose: re-establish negative pressure in the pleural space (need negative pressure for air exchange) *Look for the reason why it was placed!* pnemothorax (air = positive pressure.. put chest tube in to re-establish negative pressure!) hemothorax (blood= positive pressure.. put chest tube in to re-establish negative pressure!) pneumohemo (air & blood = positive pressure.. put chest tube in to re-establish negative pressure!) …what do you expect from a hemo chest tube: drain blood… LOCATION of the tube.. APICAL (high; air) & BASILAR (bottom; blood) example: unilateral pneumohemo.. apical for pneumo & basilar for hemo bilateral pneumo: 2 apicals chest trauma: unilateral (always assume its unilateral) post op R pneumonectomy (no chest tube!!) TROUBLE SHOOTING: Knocked it over… DON’T freak out! Water seal breaks…? CLAMP IT!!! (so nothing gets in).. CUT IT AWAY FROM BROKEN DEVICE… SUBMERGE TUBE UNDER STERILE WATER!!! UNCLAMP IT… FIRST: CLAMP BEST: SUBMERGE (re-establishes water seal) KNOW FIRST vs BEST… V-Fib.. BAD! FIRST: place backboard.. BEST: chest compressions.. What do you do if the chest tube gets pulled out? FIRST: takes a gloved hand and cover the hole.. BEST: cover it with vaseline gauze!! BUBBLING (chest tubes) Ask where & when… …Sometimes bubbline is good & sometimes it’s bad - depends on where & when! Bubbling, bubbling, bubbling… Where? Water seal.. When? Intermittent = GOOD! Document that! Bubbling, bubbling, bubbling… Where? Water seal… When? Continous = BAD! = LEAK… You do not want continous bubbling in the water seal. Bubbling, bubbling, bubbling… Where? Suction control chamber.. When? Intermittent = BAD… Suction is not high enough Bubbling, bubbling, bubbling… Where? Suction control chamber.. When? Continous = GOOD.. Document that! *If something is sealed, should you have a continous bubbling? NO. straight cath is to a foley catheter as a thorocentesis is to a chest tube.. Rules for clamping a tube: do NOT clamp longer than 15 seconds without a doctor’s order… What happens if you break the water seal? CLAMP it! How long do you have to get it under water? 15 seconds, or you gotta unclamp.. Have sterile water bottles nearby! Use rubber tip double clamps… CONGENITAL HEART DEFECTS (trouble or no trouble; either causes a lot of problems or it’s no big deal at all - there is no in between) TRouBLe Trouble defect shunts blood: RIGHT to LEFT (cyanotic); needs surgery, delayed growth, decreased life expectancy, needs more time in the hospital/pediatric cardiologist NO-trouble defect shunts blood: LEFT to RIGHT (pink); doesn’t need surgery, normal growth, normal life expectancy, only 24-36 hours in the hospital/pediatrician/NP.. 40 some congential heart defects.. TROUBLE: All start with the letter “T”; if it does not start with a “T”; it’s not trouble. TROUBLE: tetrology of fallot, truncus arteriosus, transposition on the great vessels, transposition on the great arteries, tricuspid atresia, total anomalous pulmonary venous return (TAPV), left ventricular hypoplastic syndrome… NO TROUBLE: ventricular septal defect, patent ductus arteriosis, patent foramen ovale, atrial septal defect, pulmonic stenosis… …ALL congenital heart defect kids (whther trouble or not) will have 2 things in common: they will all have a murmur (because the shunt of the blood) & they all have an ECHO done.