alaskalala

VENTS. Majority of our patients are vented for part of, and in some cases, all of their stay with us. BP management is large, maybe largest. Sometimes that's all I'm doing for 12 hours, chasing BP. One guy is sky-high, and the other is bottoming out. So you want to be brushing up on that. Not just the meds, understand your a-line. If it's not leveled correctly, or there's too much or not enough resonance in the line, you're over- or under-treating them. And if you loose that line because you don't care for it properly, that is a big fat bummer for all concerned. Do you know what a square-wave test is? Do you know what a R.O.S.E. is? What can you do to raise or lower someones pressure while you wait for the next order, or the next drug to get to the bedside? Good luck!

Thank you to all who replied. What a great resource you are, tremendously helpful. I went back to my A&P text, reread Acid/Base, F&E, and Renal chapters - surprisingly: not much there. Searched this forum for other related threads, many more details to sink my teeth into, then to the library for more books. I'm so glad this patient didn't have something very...for lack of better words, "dramatic" or "complex" going on that would have dazzled me (a ventriculostomy, multiple organ dysfunction syndrome). Otherwise, I would have missed the opportunity delve into this essential business. Can't believe how in the dark I was about it. Alarming. You study like a fiend and get good grades and think you know what you're supposed to. I'm only being introduced to the bare minimum the state requires, good thing to keep in mind. As to the source of her problem, what's causing the alkalosis: she's not on diuretics, not vomiting, no NG suction, no steroids. She's not losing acid, soooo... Even though the numbers looked like metabolic alkalosis with respiratory comp, I think the trouble was really (initially, anyway) respiratory. Here's what I think is going on: her obesity (almost 700 lbs) has been mechanically suppressing her respirations for a long time, so she's been chronically retaining CO2, and her kidneys have been compensating. Now that she's on a vent and blowing off more than she's used to, she's alkalotic because her kidneys have been holding onto bicarb and haven't adjusted yet to the lower CO2. The potassium/hydrogen exchange is what's lowering her serum K+ values. The hypokalemia is a result of rather than a cause of her alkalosis. Maybe. What do you all think of my latest interpretation?

I went back to my A&P textbook and reread the Acid/Base, F&E chapter, then the renal chapter. I'm still awash. This is one complex balancing act. Then you, Daytonite, come up with the excerpt from Methany, and blow my tentative grip on things apart. Item number two, with alkalosis shifting K+ from ICF to ECF, is what got me. Everything else I read had it the other way around: high pH shifting K+ from ECF to ICF. Methany stands alone regarding the direction of shift, but it...actually makes sense. I think it's the missing piece! I believe it may depend on which imbalance is getting a priority correction: the pH or the K+. If hypokalemia is the priority, you get alkalosis. If alkalosis is the priority, you get hypokalemia. Here's how I'm seeing it, please correct me if I got it wrong. If potassium is the priority: Low K+ Kidneys hold on to K+ Kidneys dump H+ Higher K+ (greater good) Higher pH (necessary evil) cells give up K+ cells take in H+ Higher K+ (greater good) Higher pH (necessary evil) If pH is the priority: High pH Kidneys hold more H+ Kidneys dump more K+ Lower pH (greater good) Lower K+ (necessary evil) Cells give up H+ Cells take in K+ Lower pH (greater good) Lower K+ (necessary evil) So hypokalemia can either be a cause, or a result, of alkalosis, and vice versa. Daytonite, you are likely right about the contributing factors in terms of the hypokalemia: insufficient intake of potassium, LR running for too long, loss through sweating and weeping. I still can't figure out if the alkalosis is caused by, or merely exacerbating, her hypokalemia. And if it's not the hypokalemia, what the heck is causing the alkalosis? She's not on diuretics, not vomiting, no NG suction, no steroids. But here are a few curve balls: 1)She was receiving calcium gluconate to correct the low Ca2+, doesn't calcium gluconate lower potassium levels (bad)? 2)She was on an ACE inhibitor, that blocks aldosterone, this should increase her potassium (good)? 3)I was thinking her urinary output was O.K. because it was more than 30mL/hr, but I forgot this is just a rough number based on an average 175 lb individual. She's nearly 700 lb. Urinary output should be (more precisely) .5mL/kg/hr, or in her case, about 160 mL/hr. HOLY COW! No wonder her urine was so dark. This can't be right! Does the .5mL/kg/hr still hold up for the morbidly obese? She's in the ICU of a major academic institution, there are docs of every stripe rounding constantly, would none of the nephrologists have mentioned to me that her urine output needs to be way, way higher, and would they not do something about it (diuretics)? Are her kidneys only working good enough for a 175 lb person, and essentially, failing, given her size? If so, why was her creatinine just fine? And why is nobody ordering supplemental potassium? If not for the hypokalemia, then for the alkalosis? Could it be that they were thinking the alkalosis had caused a big intracellular shift of K+, and that if they corrected the alkalosis, the ICF K+ would come rushing out, sending her into hyperkalemia? And once again, what, exactly were they doing to correct the alkalosis? Diamox is the only drug I could find that causes the kidneys to excrete bicarb. She wasn't on it. Enlightened by your post (as always), still flummoxed (a perpetual state). Care to shed more light? And thanks also for the calcium piece, binding to serum proteins, you made my night, I love to get the details on this stuff so I can understand why and how things are happening instead of just memorizing "pH up, calcium down." Ever in your debt, you patron saint of nursing students. Cass

Thanks, Anna, For confirming the intracellular shift thing. But if both calcium and potassium are shifting to the intracellular space because of the alkalosis, why replace one and not the other? I meant to say "if they HYPOventilate her" it would drop her pH, too late to be posting...brain dead. Maybe it will all be clear to me in the morning.

I'm a nursing student, doing clinical rotations in the MICU. I am digging into acid/base a little deeper than I have before. My patient had metabolic alkalosis with a little respiratory compensation, and her K+ was low (3.2), and Calcium was little low too. The docs were rounding and one of them was saying, "We're trying to get her kidney's to dump that bicarb..." I'm trying to figure out what they were doing to facilitate that. She's 40-ish, HTN, DM, morbidly obese (nearly 700 lbs). She was on LR at 100mL/hr, abx, on PC vent, an ACE inhibitor, and a minibag of calcium gluconate. It had to be either the vent settings or the calcium, right? If they hypoventilated her that could lower her pH, but wouldn't that take the pressure off her kidney's, rather than pushing them to do their job? On the subject of her kidneys, she was putting out more than 30mL/hr, her BUN was a slightly elevated, but her creatinine was fine. She might have been a little dry because she wasn't enthusiastic about PO fluids, and she was loosing a lot from weepy skin. (I don't know what her GFR was because they use an eGFR that has different values than what I learned in school). Anyway, why were they giving calcium, but not potassium? I can't find anything in my nursing texts about the relationship between K+ and metabolic alkalosis. I'm kind of lousy at Googling, always end up 250,000 hits, the first 20 of which are completely over my head, at which point I usually give up, and go back to studying what I'll actually be tested on, instead of these clinical rotation mysteries. Anyway, on the internet, I come across something that says depleted potassium can contribute to reabsorption of bicarb in the proximal tubule. Then I come across something else that says that in metabolic alkalosis K+ shifts into the intracellular space. In that case, low K+ isn't really depletion, it's just a low serum level because it's disappeared into the cells. So, that might explain why the docs wouldn't correct the hypokalemia with potassium, because it's not a question of too little, it's a question of where it is. But I'm severely muddled on this. My question is: does hypokalemia contribute to alkalosis, or is it a result of alkalosis? And, what can be done to help the kidneys reverse the alkalosis? And what does calcium gluconate have to do with it all (if anything)? O.K., that's three questions. Can anyone shed some light on my dim head, or point me to places to read up on this? Forgive my ignorance, doing the very best I can. Most grateful for any assistance.

I am digging into acid/base a little deeper than I have before. My patient had metabolic alkalosis with a little respiratory compensation, and her K+ was low (3.2), and Calcium was little low too. The docs were rounding and one of them was saying, "We're trying to get her kidney's to dump that bicarb..." I'm trying to figure out what they were doing to facilitate that. She's 40-ish, HTN, DM, morbidly obese (nearly 700 lbs). She was on LR at 100mL/hr, abx, on PC vent, an ACE inhibitor, and a minibag of calcium gluconate. It had to be either the vent settings or the calcium, right? If they hypoventilated her that could lower her pH, but wouldn't that take the pressure off her kidney's, rather than pushing them to do their job? On the subject of her kidneys, she was putting out more than 30mL/hr, her BUN was a slightly elevated, but her creatinine was fine. She might have been a little dry because she wasn't enthusiastic about PO fluids, and she was loosing a lot from weepy skin. Why were they giving calcium and not potassium? I can't find anything in my nursing texts about the relationship between K+ and metabolic alkalosis. I'm kind of lousy at Googling, always end up 250,000 hits, the first 20 of which are completely over my head, at which point I usually give up, and go back to studying what I'll actually be tested on, instead of these clinical rotation mysteries. Anyway, on the internet, I come across something that says depleted potassium can contribute to reabsorption of bicarb in the proximal tubule. Then I come across something else that says that in metabolic alkalosis K+ shifts into the intracellular space. In that case, low K+ isn't really depletion, it's just a low serum level because it's disappeared into the cells. So, that might explain why the docs wouldn't correct the hypokalemia with potassium, because it's not a question of too little, it's a question of where it is. But I'm severely muddled on this. My question is: does hypokalemia contribute to alkalosis, or is it a result of alkalosis? And, what can be done to help the kidneys reverse the alkalosis? And what does calcium gluconate have to do with it all (if anything)? O.K., that's three questions. Can anyone point me to places to read up on this? Forgive my ignorance, doing the very best I can. Most grateful for any assistance.

Thanks, Jules, for the offer to help prioritize. I usually do o.k. there. It's providing a rationale for my choice that hangs me up. And thanks, Daytonite, for the expanded Maslow. I like how the ABC's are incorporated. And I've never seen a prioritization of oxygenation by organ before, LOVE IT. Not intuitive for me, I would have thought just the opposite, lungs first, then heart, then brain. But time to loss of function wasn't something I took into consideration, makes perfect sense. Yes, as a matter of fact, my instructors do seem to make pain a priority diagnosis, and I am not clear on why. If the air isn't going in and out, or the blood's not going round and round, your pain takes a backseat to my mind. And if a patient's pain is such that it's interfering with something of a higher order (i.e., it's making them hyperventilate), then I don't see why my priority dx wouldn't be: ineffective breathing pattern r/t pain AEB hyperventilation, with an intervention to provide pain meds. Yes, they're tied together, but effective breathing is more critical than comfort. The intervention (pain meds) is the same as if my dx was acute pain, but I'd be wrong, priority dx-wise, at school. Ah, well, mine is not to question why, mine is to figure out the rules and play ball. I just wish the rules were consistent and written down somewhere. "But they are," you say. Unfortunately, sticking to NANDA and Maslow is not encouraged in the program. We are encouraged to make these up, so as to exercise critical thinking, so as to be more client-specific. With the exception of pain, I usually get the priority dx right. However, the rationale I'm to write should explain WHY I choose one dx as the priority over another dx. I like structure. I'd like to be able to follow the Maslow's, in order, and give that as my rationale. Something like, "according to Maslow, the need for oxygen and to breath is a higher priority than comfort." But that ain't workin' for my instructors. They want something else. What? Beats me. I just started doing these in September, so it's all fairly new to me. I think I'm going to go online and get ten or twenty case scenarios, pick a priority dx and write a rationale for my choice, and take the whole works to an instructor for feedback. This one care plan, once a week thing, is just not enough feedback to learn the rules. Thanks again to both of you.

Our weekly care plans ask for our top three nursing diagnoses. Out of the three, we are asked to choose the PRIORITY dx (and give a care plan for it), and to provide a rationale for why this particular dx is our top choice. I can come up with loads of dxs for my patients. So I usually think to myself: what could kill this person now, this shift, or soon? If one of them fits the bill, that's my priority. I go down the ABC's, and if they are all good, up Maslow's hierarchy. Easy. If nothing will kill them soon, then I get fuzzy. And sort of look at all my dx's and let the one that "seems" most urgent grab me. Maybe I'm even letting which one is the easiest or quickest to fix grab me. I'm not sure. I'm flummoxed when it comes to writing the rationale for my choice. Since I choose the "it'll kill you quicker" ones by a process of elimination, my rationale doesn't sound like a "rationale." In my head, my rationale sounds like this: "No airway problem, breathing...breathing problem -- stop -- priority dx," or "No airway, breathing, circulation problems, moving on to Maslow, physiologic needs...fluid problem -- stop -- priority dx." For the "it won't kill you any time soon, but it certainly sucks" ones, I really don't know how to justify my choice. "This one's easy/quick to fix so let's just knock it off your long list of sucky things," or "This one's not so sucky now, but let's begin to tackle it so it doesn't turn into an 'it'll kill you' one." I like to keep things simple, but I'm feeling like maybe I need more ways to look at, and more clarity, on WHY or HOW I choose the priority dx. I don't know how to phrase my question here anymore precisely, than to say: I feel like something's missing. Maybe I'm looking at this whole thing the wrong way. I feel like I'm looking at the negative side, i.e., imagining the worst-case scenario for my patient and trying to avoid that. Should I be imagining their best-case scenario, their "ultimate" goal, would that help? I wonder if my fear about missing something important (as an inexperienced nursing student) is skewing or narrowing my view, and if I should begin to incorporate another, broader, perspective on care. Right now, I could sure use a better rationale than, "well, er, um, everything else that's more important is O.K., and everything else that's less important is, um...less important?" Any thoughts would be most welcome.

I was in your shoes last year. Impossibly long wait list where I lived (Alaska). I had no choice but to relocate and searched high and low, all over the US. Scarey! Wait lists everywhere, except a few private colleges that wanted 20 grand a year. Finally found a great school with no wait list and very reasonable tuition. Maria College in Albany, NY. I took the entrance exam April 18th and began the program in May. They have an LPN and RN program and are in the process of BSN certification. The cohesion of their program is very unusual (and the way of the future, one would hope). It's a 1 + 1 + 2 option. You can (1) begin in May as an LPN student, get your LPN certification the following August then transfer directly into the second year of the RN program (+1). This allows you to work part-time as an LPN, earning money and nursing experience while completing your RN. If you then want to go on for your BSN, just add two more years. It sounds like you have some general education requirments taken care of already, so your ahead of the game. The LPN program is a weekend schedule (all day Saturday and Sunday) leaving you M-F to study, work, & live. Much more appealing to me than an hour or hour and a half class here there and everywhere throughout the week. The school is small so all the administrative details are a breeze to negotiate, you aren't waiting on line, or being put on hold, or getting lost in the shuffle. The faculty I've had have all been great. I can't recommend it highly enough. Relocating was rough, but I just couldn't put up with the crazy wait. I'll have my RN completed before the University of Alaska would have let me take my first nursing course. And I've been pleasantly surprised by Albany, a very livable town. Private Message me if you want more details. Good luck.

Cherryswitch, I take my NLN pre-admission test in April, and I'm really nervous -- so much riding on one test. I have been working through the review guide by McDonald this week, but it would be a tremendous help if you could advise on where to focus my study efforts. I'm not worried about the verbal section, however, math & science: Yikes! I've been out of school for 20 years and never took physics at all. I use dimensional analysis well, but I don't really know what conversion factors or formulas to memorize. Can you help? Thank you, and congratulations on the 99th percentile!

Rightalong, I'm only pre-nursing student, so I can't help you with the agency questions, but I have lived in Alaska for almost 20 years, so I think I can contribute to your other questions. You can drive up to Bellingham, Washington, and get on a ferry with your car there. The ferry will stop in Sitka, so if you work there, there you are. You do know it's an island, right? Meaning, if you work there you will need to fly to other parts of Alaska, and rent a car, unless you want to drag your car back and forth on the ferry. To get to Anchorage, you would get off the ferry in Haines, then drive up through Canada and over and down through Alaska. The roads are fine, though jammed with RV's in the summer. In the winter, a bad storm can make some passes on the road scarey. Four-wheel drive and snow tires are a good idea. Whoever told you about it being dangerous to drive around Alaska, "people disapearing" and such, doesn't know a thing about Alaska. That's just crazy talk! It is actually against the law to pass by an accident or someone stuck on the side of the road without offering assistance, honest to God, though only someone from the lower 48 would need a law to make them stop and help. I'd rather drive in Alaska than New Jersey any day (and I grew up in New Jersey so I can make a fair comparison). The only problem with driving in Alaska is you run out of road pretty fast. I would recommend working in Sitka or Anchorage. Fairbanks is way too hot and smokey all summer (forest fires), way too cold in the winter, far from the ocean, and not very pretty. Sitka is a beautiful island in the rainforest. Anchorage is a big city on Cook Inlet, and if you like to drive, there are roads south to the Kenai Penninsula, north to the Alaska Range (Denali National Park etc.), east to the Wrangell-St. Elias Range. For further information on the ferry look on the web for the "Alaska Marine Highway" site. If you have any other questions about Alaska, please feel free to ask. I love this place and would be happy to help another Jersey Girl come up and enjoy herself. Alaskalala