Dinith88

Yes...but...ICU nurses are still cooler than ER nurses.

??? Are you sure you mean this??? ...Will someone please stand-up and correct this statement ?

The IV-push dose is given in codes...when the patient is down. 10 minute 'rapid load' is for people who are in a fast rhythm but not yet down. IVP isnt recommended IVP for people who arent actively coding d/t the potential side effects...most notably (but not limited to) severe hypotension (esp. if given IVP!). If patient was on the brink...the IVP amio could send them over...

In isolation, the QRS/picture you were given is likely (for your 'class') to indicate MI. SIRI pointed out why it would indicate MI. If you want to get specific (and likely impress your anatomy teacher), you can also conclude (by this picture) that the MI is 'transmural'. This can be distinguished by the deep Q-wave. 'Transmural' means the infarction has extended through the entire wall of the myocardium.These deep q-waves usually stay with the patient (on subsequent EKGs) for the rest of her life...and can be thought of as scars...and can be seen on someone who's not actively having and MI. (You can have MI's that dont extend through the entire wall...these are known as Non-Qwave MIs (no Q-waves), non ST-elevation MI, or Acute Coronary Syndromes, etc.) The elvated ST (again in this isolated picture) lends itself to the acute stage of MI because the ST elevation indicates actively 'dying/injured' myocardium. Check out SIRIs picture again...and think of like this: 1) ST-segment/T-wave inversion represents ischemic myocardium.. 2) ST elevation represents damaged/dying myocardium.. 3) Deep Q-waves represent dead/scarred myocardium.. And...like others have said....in reality you need more information and such...but for the purposes of your class i'm betting thats what your teacher was getting at...

Then you are wrong like H-town.

Good Question! OK my quick answer is: Used to be everyone with a Dx of CHF got Dig. Not true anymore. Treatment of CHF with dig (these days) is individualized. This is mostly because there is evidence that dig has no long-term effect on mortality...BUT is useful in certain patients (mostly with Systolic heart-failure...patients with diastolic heart-failure arent afforded any benefit from dig) Probably best to look at the individual patient...do they have a Hx of a-fib/atrial-tachy-rhythm problems, systolic-vs-diastolic CHF, etc.? And, you ask good questions about beta-blockers and their potential effect on reducing cardiac output...and the old-school cardiology thought was just that. They weren't prescribed for everyone with CHF but rather reserved for HTN, tachy-arrhythmias, etc.. BUT.. now, there is a wealth of evidence that beta-blockers do reduce mortality/morbidity in CHF (as you mentioned) and can help slow it's progression. This mechanism is mostly a matter of reducing/delaying myocardial remodeling, reducing myocardial O2 demand, etc. So...your next assignment is to learn the difference between systolic and diastolic heart failure...

I'm unsure of the specific vapors, humors, and phlegms behind the BP-regulating function of cortisol but i do know that it's not a simple matter of volume expansion. Cortisol has more of a 'metabolic' rather than 'mechanical' effect on BP...if that makes sense (it's very early here). But...what I am sure of is that it's not going to improve hypotension in someone who's not adrenal insufficient. For example, it wont do a thing for cardiogenic or hypovolemic shock...BUT it can help (and sometimes dramatically) in certain distributive (esp. septic) shock-states...or any other incidence where the adrenals are failing. MANY patients in septic-shock have depressed adrenals... But...to make my early morning...long-winded answer short... Cortisol administration only helps improve BP if adrenal insufficiency is causing and/or otherwise involved in the hypotension. And...it's more than a simple matter of volume expansion.

Nothin better than a confused neuro patient who's fighting and trying to climb out of bed with drains and wires in their heads/brains. Fun. Love that. Hope you keep your enthusiasm!

Next time he comes in, punch him in the nose. He'll stop acting like an idiot at that point.

Good Job! A rr-10-12 is normal and wouldnt account for a pCO2 in the 50's. (meaning it's another clue that he's not in a metabolic alkylosis with resp compensation) Also, he wouldn't be considered 'a little over-compensated' because his pH is normal. Good thing he pooped. Bad thing he coded.

Look, this patient has 20 reasons to be disoriented/confused(the MRI showed brain swelling for goodness' sake). The OP asked why the patient 'when awake' (and not being sedated with dangerous medicine) is agitated and pulling at things and trying to get out of bed. It's silly for people here on this thread to try and pinpoint a medical reason for it (like i said he has 20 different reasons to be confused) The answer to her question isnt about what diagnosis is causing it (if it IS asking this, the question is misguided) But rather what motivation is driving his behavior. Ask any experianced nurse that works with alzheimers/dementia patients. The number one reason why these innapropriate behaviors escalate is because...they have to poop. Constipation. As i said, anything else is a guess. A bowel movement emergency is as good a guess as any.

To continue on with this point...perhaps to help you better understand... 1) To hypoventilate to the point that your pCO2 is 52, you'd have a (dramatic) low pO2 as well...and OP's pt is only on 33% FiO2 2) OP mentions patient receiving propofol and versed...which means patient is likely intubated. If this is the case the ventilator would prevent any 'compensatory hypoventilation'. 3) a 'true' metabolic alkylosis is very rare. If you were correct in your diagnosis, the patient is in a PROFOUND metabolic alkylosis (as it requires a pCO2 of 52 to 'compensate'). What in the pt's description leads you to even suspect a metabolic alkylosis???

Nope. Compensated respiratory acidosis. Chronic.

At first glance the ABGs look like a chronic CO2 retainer's. (high CO2, high HCo3, normal pH) Does he have Hx of Smoking? COPD? I know you mentioned he has lung mets... Keep in mind that the body takes weeks/months to compensate for chronic CO2 retention...so when you see this normal pH in combination with high HCO3 it's always a good guess. It's likely not an acute compensation.

A VERY good guess is that He has/had to poop. (before you write this off as a joke, it's not.) He just couldnt communicate it...and was doing everything in his power to not poop the bed. Any other answer to your 'why is he agitated' question will be a guess. Mines as good as any.

Thats all well and good. But...how are you with POOP. On your clothes. On your arm. Shoes. Nostrils... Good luck to you in your poopy-slop journey...I hope you stay excited.

Again, you're mistaken. My suggestion to you (or anyone else who is reading this) is to re-read my post/posts...after re-reading the OP's. I apologize if you felt i was degrading...that was not the point. But...i DID get your goat...

Nah...you're mistaken. The OP stated people 'using ER as primary care' was one such sub-category of ER-abusing system-ruiners. The three examples were all things that could've been seen and taken-care of by primary care. Or...do you HONESTLY think that anyone who starts barfing needs to head to an emergency room??? Ha!

A young mother brings her child in because she was up crying and complaining of belly pain...(and who turns out to be constipated) Or a person comes in with strep-throat in the middle of the night (ouch..have you had that? it's probably an emegency for him) Or, a person comes in with a stomach-virus and barfs all over...could've stayed home (but it was an emergency for him) These corny examples (like a bazillion others) probably sound very familiar to ER nurses. To judge these 'visitors' poorly because they're not 'really' sick (ie using ER as 'primary care', or coming in for 'stupid complaints' like the OP stated), is an insight into an ER-nurses character. Not all ER nurses...but the ones who think-it/say-it/post-it. I think the nurse who developes this attitude is primarily the one who had an incorrect vision of what the ER is. Like theOP said, if you want to work ONLY with unstable patients then ER is the wrong place to work. The reality of the ER is FAR from what the TV shows portray (you know that)...yet it is this very illusion that draws alot of folks to work there. (another interesting insight into the minds of many ER nurses can be seen @allnurses...common/popular themes on the ER boards are "...what was the stupidest patient complaint..." or "lets make fun of dumb people.."...and various other silly (but entertaining) threads...) Like it or not, ER's (by their very nature and because of the forces of the system we're all a part of) function primarily as a high-powered, 24/7 doctors office. MOst patients dont get admitted...and only a small percentage of these are unstable. Mix in the occaisional tragic stories (ie young dead people, traumatic limb amputations, splattered brain matter, etc.)...and there you have it. An office nurse who is a sporadic witness to some awful stuff (...the 'fun' stuff that the aforementioned angry-posting-patient-haters 'really' like...to hell with barf and strep-throat! :) ). Now...let me step down from my soap box...and whisper that i agree with you...

Yes it will cause issues...despite the high-minded statements like "it's what's inside that counts!"...and..."it has no bearing on your work performance!" A man wearing make-up, or nurse-dresses, or nurse-hats will turn peoples heads and make them giggle and even offend certain people. And i'm betting even non-homophobic (mostly male)-patients will be terribly uncomfortable with you in a role that requires close personal contact. Through no fault of your own...of course. You will be talked-about and ridiculed (mostly in secret-behind-your-back) and have lots of negative experiences... But...I've a hunch you know and expect this...as it probably follows you outside of any workplace. And...i'm sure you're proud and determined and free and all of that... but, would it pain you to keep your alter-ego/make-up/girl-clothes at home while @ work?

Ah...the luxuries of ER nursing...

Yes you will see lots of unfortunate situations like that. And yes because of your (our) self-appointed moral high-ground you'll rant and yell about it...to yourself and to others and to the gods..and... You just have push ahead. All ICU nurses (at least all the good ones :) ) are affected by it. Will it run you out of the Unit? Maybe. It does alot of folks. But... We have to do our jobs...and what the family wants. Also...the ICU corpses on life support are FAR different from the hospice experience many of us are familiar with. In ICU the families are freshly in shock, in crisis, in anger, helpless,..(and all the other stages of grieving, etc). You have to sit with them, council them, dodge their punches, etc...When this process nears completion and they're accepting...then it becomes more of a hospice-type experience... AND...thats just ONE of the cultural/moral/existential/alcoholism-inducing aspects of the ICU...to say nothing of the work...and it's just the tip of the iceburg.

And one other thing to consider... A pure respiratory alkylosis means a person is hyperventilating enough to throw off the body's acid-base balance. If this person has hyperventilated to this point he/she is going to feel VERY strange/sick/dizzy/whatever...(which would make it VERY hard for person to maintain) The kidneys (body's primary 'bicarb factory') can take many days/weeks to compensate for respiratory-driven acid/base disturbances. (Which is why they cant help/compensate in acute hypercapnia's, etc...) So...again assuming a person is hyperventilating enough to become alkylotic (and feeling all the symptoms that go with it), they would have to maintain this hyperventilation for many days/weeks before you might see any type of metabolic compensation....or a 'compensated/partially compensated respiratory alkylosis'...and would be an extremely unusual case.

The term 'overcompensation' was a made up word. The idea of 'overcompensation' that i brought up was referring(sp?) to a hyperventilated patient on a ventilator (man made, not body-made)---which happens. Patient starts out acidotic...the vent settings (TV, RR, etc) are too high and CO2 drops lower than desired...giving you an alkylotic Ph. AND...you dont/shouldnt treat metabolic acidosis with ventilator manipulation. It's poor practice. Makes numbers(ph) look better but does nothing to address(sp?) the underlying issue. The OP would agree with you (and others) that if you follow the Text-books on ABG interpretation, step one is to look at Ph, step two look at CO2. The OP did this...and correctly determined (as did you) respiratory Alkylosis. But...The origional question was why did the surgeon say the patient was Acidotic. And yes..bicarb could be low d/t renal function...or a bazillion other reasons. But (whats funny) is that when you say this, you're speaking out of both sides of your mouth ie. 'patient's alkylotic...but could be acidotic from renal failure'. Any human being that has (by ABGs) a bicarb of 18 and a BE of -4 wont be walking around feeling OK (with marginal kidney function as you suggest). They'd be sick as all get-out, huddled on a bed somewhere hyperventilating. This hyperventilation IS a compensatory mechanism and the patient MAY have a normal ph. (or even slightly alkylotic) but is still acidotic. ((i guess this last example is to show that by hyperventilating you are able to develope a (temporary)respiratory alkylosis in the face of a metabolic acisodis...and could in effect actually be a body-driven(rather than ventilator-driven) 'overcompensation'))...

Oh yeah! Again, the REAL reason why most female ER nurses (vast majority) think EMTs are "good help in ER...we should embrace them" (no pun intended!) Awesome!