Help!

13 Apr

Help by Fellow World

Click on the art to credit the artists.

Help me, I am stuck in that tree.  April 21 I will be taking the PCCN cert exam. I am a good test taker, I can eliminate the wrong answers. I can do that.

It is kind of like knowing what you do not want, but never knowing what you do want.

Somebody help me. It is cold and cloudy, and I just can’t sit any longer. Please tell me I am not all alone in this!

Just what does Potassium 3.5-5.0meQ/L do? it maintains intracellular water and acid/base balance.

Hyperkalemia is usually caused by renal failure. The symptoms of this may be bradycardia, tremors, twitching, tall peaked T waves. The treatment is: Kayexelate, dialysis, insulin/D50, or HCO3/Ca++.  It can take a while for the Kayexelate to work. I once had a patient NPO and the nephrologist actually wanted me to give the Kayexelate via rectal enema.When I asked him how was I supposed to keep the medicine in the rectum long enough for it to work, he told me to use a “butt cork”!  I bothered him till he cancelled that request and changed his mind to give HCO3.

Hypokalemia can be caused by inadequate intake or renal loss. NPO patients should be getting KCl 40meQ each day somehow. The symptoms are tachycardia, hypotension, flaccid muscles, and flat T waves. The treatment is: give KCl orally preferably, or IV.

Calcium 8.4-1.2mg/dL is needed for the contraction of the heart and blood vessels and coagulation.

Hypercalcemia is caused by bone loss or destruction. The symptoms are coma, flaccid muscles, short ST and QT interval. The treatment is IV fluids, diuretics and phosphate.

Hypocalcemia is caused by a low albumin, multiple blood transfusions. The symptoms are seizures, laryngeal spasm, hypotension, flat ST, and a small T wave. The treatment is calcium gluconate.

Magnesium 1.5-1.95meQ/L , my most favorite electrolyte of all! It is needed for the relaxation of the heart and blood vessels and it is NEEDED for the absorption and utilization of other electrolytes. Stop running those K riders, if the Mg is low you are wasting time and burning the veins if you do not replace the MG too! We like the Mg above 2! ❤

Hypermagnesemia is caused by renal failure. The symptoms are CNS depression, hypoactive reflexes, bradycardia, and hypotension. It is treated by giving IV calcium.

Hypomagnesemia is caused by inadequate intake. The symptoms include irritability, increased reflexes, ST depression, and T wave inversion. The treatment is Magnesium. I think I will go take some oral Mg right now.

Phosphorous 2.5-4.7mg/dL is essential for ATP production. Our cells need that energy.

Hyperphosphatemia is caused by renal failure. The symptoms are asymptomatic but you will see a low calcium. The treatment in Amphogel, Insulin/D50, Dialysis, Fluids.

Hypohosphatemia is caused by Mg deficiency, re-feeding syndrome, acute respiratory distress. The symptoms look like a decreased level of conciousness, respiratory distress, muscle weakness. The treatment is: phosphorus.

Sodium 135-145mEq/L is needed for water movement and the changes may cause cerebral edema.

Hypernatremia is caused by fluid loss. The symptoms are thirst, and CNS depression. The treatment is free water D5W. If they have a PEG tube you will be shoving in tap water bolus.

Hyponatremia is caused by overhydration with IV fluids sometimes. The symptoms are edema and mental status changes. The treatment is a fluid restriction, normal saline, or hypertonic saline. I was so afraid to run hypertonic saline the first time. The patients sodium was like 109.

The medications on the PCCN test with the desired effects!

Let’s make it easy!

All of the following medications increase the heart rate, the blood pressure and the cardiac output, these winners are:

Dopamine 2-20 ug/kg/min- Dobutamine 5-15ug/kg/min–Levophed 2-12 ug/kg.min–Epinephrine 1-10ug/min

Got that? OK give me some LOVaphed, will that be on the test? I know about that drug.

The next medication Digoxin 0.125-o.5mg will decrease the heart rate, actually increase the blood pressure (diastolic especially but don’t quote me on that) and increase the cardiac output.

The Nitroglycerine 5-20ug/min does nothing to the heart rate, it decreases the blood pressure and can either increase or decrease the cardiac output.

The Nitroprusside 0.1-10ug/kg/min increases the heart rate, decreased the blood pressure and cardiac output.

The Amiodarone Bolus 150-300mg followed by drip decreases the heart rate and blood pressure and increases the cardiac output. I have a love/hate relationship with Amiodarone.

Next!

Localizing the injury on the 12 lead EKG

Trouble: T wave inversion is ischemia. ST segment elevation is injury and Q waves indicate necrosis.

First find out if the changes are in more than 1 lead or every lead.

Next!

The vessels LCD and the LAD affect the anterior heart, the changes are in lead V3, V4

The vessel RCA affects the inferior heart and the changes are in lead II, II, AVF And remember with an inferior wall MI we are supposed to get a right-sided EKG which I have never even seen before!

The vessels LCA and the Circumflex affect the lateral heart and the changes are in V5, V6, I, aVL

The vessels LAD and PDA affect the posterior heart and the changes are reciprocal in leads V1-V4

The RCA vessel also affects the right ventricle and is present in V4R

Go memorize.

Now for my favorite part where all of you are going to pee pee in your panties!

H20+CO2=H2CO3=H+HCO3

Water and carbon dioxide equals carbonic acid equals hydrogen and bicarbonate! <giggles>

I loved chemistry in nursing school. I almost changed course on the ship of academia, but I held onto nursing steadfast.

It is just a balancing act this acid base balance and our lungs and our kidneys are working hard at it, even if you do not feel it.

Maybe I feel it. I like HCO3 in my mouth when I brush my teeth with baking soda like the old days when there was no toothpaste in the medicine cabinet. Just dip your brush into a box of Arm and Hammer and rinse it out with hydrogen peroxide. I bet you will have white teeth just like me, even if my teeth are slightly crooked. I like them that way, but I better stop licking them with my tongue, I do not want to get subacute bacterial endocarditis or something.

Anyway on with the ABGs

pH 7.35-7.45

pCO2 35-45mmHg

pO2 80-100mmHg

O2 sat 95-100%

HCO3 22-26mEq/L

Base Excess + or -2

Forget about the Anion gap-that better not be on the test! If it is I will punch the computer module and walk out. Just kidding!

So we have the lungs that remove CO2 that is made by cellular processes. That is what the lungs do to balance the pH. The kidneys balance by producing HCO3 and by getting rid of H+ ions. The way these organs interact is via the making of carbonic acid H2CO3, which is a constant thing. The water will attach to carbon dioxide, then when needed this breaks apart to make hydrogen ions and bicarbonate.

It is just a continuous, compensating balancing act to keep the pH normal.

I doubt that chemistry will be on the exam so here I will put it to use.

1. A 60 year old liver transplant patient with pneumonia, a room air ABG reveals: pH 7.46 (alkalosis) CO2 32 (alkalosis) pO2 77 (hypoxemia) O2 sat 96% (normal) HCO3 23 (normal)

The patient is mildly hypoxic with uncompensated respiratory alkalosis. From the low pO2 the patient might be breathing faster, blowing off the CO2 causing this problem. There will probably not be any treatment for this at this time.

2. A 22 year old has been fasting to lose weight. She is a diabetic. Noone is sure if the patient has been taking the insulin at home for a couple of days. ABG goes like this

pH 7.20(acidotic) CO2 28 (alkalosis) pO2 96 (normal) O2 sat 96% (normal) HCO3-11 (acidosis)

The patient has partially compensated metabolic acidosis from DKA. The treatment is to correct the glucose with insulin and IV fluids. If the internal medicine doctor tells you to give bicarbonate: don’t do it! It will not fix the pH and will mask the underlying problem.

3. 60 year old with chronic renal failure complaining of dizziness. ABGs are drawn.

pH 7.37 (normal) CO2 34 (alkalosis) pO2 94 (normal) O2 sat 97% (normal) HCO3 19 (Acidosis)

Common to renal failure this is fully compensated metabolic acidosis. No treatment.

Pt admitted for COPD. ABG

pH 7.33 (acidosis) paCO2 60 (acidosis) pO2 75 (hypoxemia) O2 sat 94% (low) HCO3 31 (alkalosis)

This is partially compensated respiratory acidosis and the patient will probably get a BiPAP on telemetry!

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: