Answers to practice ABG's: #12 pH 7.
#12 pH 7.4 = perfectly normal
#1 pH 7.52 = alkalosis
pCO2 40 = normal
HCO3 35 =metabolic alkalosis
Metabolic alkalosis (no compensation)
#2 pH 7.25 = acidosis
pCO2 60 = respiratory acidosis
HCO3 27 = slight metabolic alkalosis
Respiratory acidosis, and kidneys are beginning to
compensate (retain
bicarb. Note that the pH has a long way to go before acidosis, with complete
it comes back into
normal range, so compensation has just begun.)
#3 pH 7.25 = acidosis
pCO2 40 = normal
HCO3 12 = metabolic acidosis
Metabolic acidosis (no compensation)
#4 pH 7.55 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 26 = normal
Respiratory alkalosis (no compensation)
#5 pH 7.29 = acidosis
pCO2 20 = respiratory alkalosis
HCO3 18 = metabolic acidosis
Metabolic acidosis with some compensation by the personality disorders, including the following:
lungs (not very effective;
has not returned pH to acceptable range yet)
#6 pH 7.48 = alkalosis
pCO2 50 = respiratory acidosis
HCO3 34 = metabolic alkalosis
Metabolic alkalosis with almost complete
compensation by the lungs
#7 pH 7.5 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 30 = metabolic alkalosis
Combined respiratory & metabolic alkalosis#8 pH
7.18 = acidosis
pCO2 60 = respiratory acidosis
HCO3 26 = normal
Respiratory acidosis
#9 pH 7.29 = acidosis
pCO2 60 = respiratory acidosis
HCO3 35 = metabolic alkalosis
Respiratory acidosis with some compensation from
kidneys
#10 pH 7.48 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 34 = metabolic alkalosis
Combined respiratory and metabolic alkalosis
#11 pH 7.43 = normal
pCO2 35 = normal
HCO3 23 = normal
Normal
behavior is often aggressive, impulsive, reckless,
pCO2 60 = respiratory acidosis
HCO3 30 = metabolic alkalosis
Two imbalances with complete compensation, so it
is difficult to tell which is
the problem and which is the compensation.
However, since only the kidneysare strong enough
in compensation to bring the pH back to perfectly
normal, the primary problem has to be respiratory
compensation by the kidneys.
Personality Disorders
Personality disorders are stable patterns of experience
and behavior that differ noticeably from patterns that are
considered normal by a person’s culture. Symptoms of a
personality disorder remain the same across different
situations and manifest by early adulthood. These
symptoms cause distress or make it difficult for a person to
function normally in society. There are many types of
• Schizoid personality disorder: entails social
withdrawal and restricted expression of emotions
• Borderline personality disorder: characterized
by impulsive behavior and unstable relationships,
emotions, and self-image
• Histrionic personality disorder: involves
attention-seeking behavior and shallow emotions
• Narcissistic personality disorder:
characterized by an exaggerated sense of
importance, a strong desire to be admired, and a
lack of empathy
• Avoidant personality disorder: includes social
withdrawal, low self-esteem, and extreme
sensitivity to negative evaluation
• Antisocial personality disorder: characterized
by a lack of respect for other people’s rights,
feelings, and needs, beginning by age fifteen.
People with antisocial personality disorder are
deceitful and manipulative and tend to break the
law frequently. They often lack empathy and
remorse but can be superficially charming. Their
• · Conversion disorder : Involves unexplained,
and irresponsible. Antisocial personality disorder
has been referred to in the past as sociopathy or
psychopathy.
• Somatoform disorders
• Somatization: The transference of mental
experiences and
• states into bodily symptoms.
• Somatoform disorders: Characterized as the
presence of
• physical symptoms that suggest a medical
condition without
• demonstrable organic basis to account fully for
them. The
• three central features of somatoform disorders
are as
• follows:
• · Physical complaints suggest major medical
illness but
• have no demonstrable organic basis.
• · Psychological factors and conflicts seem
important in
• initiating, exacerbating, and maintaining the
symptoms.
• · Symptoms or magnified health concerns are not
under
• the client’s conscious control.
• The five specific somatoform disorders are as
followed:
• · Somatization disorder : Characterized by
multiple
• physical symptoms. It begins by 30 years of age,
• extends over several years, and includes a
combination
• of pain and GI, sexual, and pseudoneurologic
• symptoms.
• o Client’s jump from one physician to the next, or
• may see several providers at once in an effort to
• obtain relief of symptoms.
• o They tend to be pessimistic about the medical
• establishment and often believe their disease
• could be diagnosed of the providers were more
• competent.
usually
• sudden deficits in sensory or motor function
(blindness,
• paralysis). These deficits suggest a neurological
• disorder but are associated with psychological
factors.
• An attitude of la belle indifference, a seemingly
lack
• of concern or distress, is the key feature.
• · Pain disorder : Pain is the primary physical
symptom
• which is generally unrelieved by analgesics and
greatly
• affected by psychological factors in terms of
onset,
• severity, exacerbation, and maintenance.
• · Hypochondriasis : Preoccupation with the fear
that one
• has a serious disease (disease conviction) or will
get a
• serious disease (disease phobia). It is thought that
• clients with this disorder misinterpret bodily
sensations
• or functions.
• · Body dysmorphic disorder : Preoccupation with
an
• imagined or exaggerated defect in personal
appearance
• such as thinking one’s nose is too large or teeth
are
• crooked and unattractive.
• Symptoms of a somatization disorder
• · Pain symptoms : complaints of headache, pain in
the
• abdomen, head, joints, back, chest, rectum; pain
during
• urination, menstruation, or sexual intercourse.
• · GI symptoms : nausea, bloating, vomiting (other
than
• pregnancy), diarrhea, or intolerance of several
foods.
• · Sexual symptoms : Sexual indifference (don’t
care to do
• the dirty), erectile or ejaculatory dysfunction,
irregular
• menses, excessive menstrual bleeding.
• · Pseudoneurologic symptoms : Impaired
coordination or
• balance, paralysis or localized weakness, difficulty
• swallowing or lump in throat, aphonia (loss of
speech
• sounds), urinary retention, swollen tongue,
• hallucinations, double vision, blindness, deafness,
• seizures; disassociative symptoms such as
amnesia; or
• loss of consciousness other than fainting.
• volunteers. • · Ineffective coping • improve the client’s confidence in making
• relationships.
• · Primary gain : Direct external benefits that being • o The client will identify the relationship between
sick • stress and physical symptoms. • · Anxiety
• provides, such as relief of anxiety, conflict, or • o The client will demonstrate alternative ways to
• Emotion-focused coping strategies help the
distress. • deal with stress, anxiety, and other feelings
• • clients relax and reduce feelings of stress.
· Secondary gains : Internal or personal benefits
• This includes progressive relaxation, deep
• · Disturbed sleep pattern
received
• from others because one is sick, such as attention • breathing, guided imagery, and distractions • o The client will demonstrate healthier behaviors
from • such as music. • regarding rest, activity, and nutritional intake.
• family members and comfort measures (being
• Problem-focused coping strategies help to • The nurse explains that inactivity and poor
brought
• resolve or change a client’s behavior or • eating habits perpetuate discomfort and that
• tea, receiving a back rub).
• Treatment:
• situation or to manage life stressors. This • often it is necessary to engage in behaviors

• • even though one doesn’t feel like it.

• Related disorders:
• •
· Malingering : The intentional production of false
or
• grossly exaggerated physical or psychological
• symptoms; it is motivated by external incentives
such
• as avoiding work, evading criminal prosecution,
• obtaining financial compensation, or obtaining
drugs.
• Their purpose is some external incentive or
outcome
• that they view as important and results directly
from
• their illness. People who malinger can stop the
physical
• symptoms as soon as they have gained what they
• wanted.
• · Factitious disorder : This is also known as
Munchausen
• syndrome. Occurs when a person intentionally
produces
• or feigns physical or psychological symptoms
solely to
• gain attention.
• o Munchausen syndrome by proxy occurs when a
• · Cold intolerance
person inflicts illness or injury to someone else to
• gain the attention of emergency medical
• personnel or to be a “hero” for saving the victim.
• This occurs most often in people who are in or
• familiar with medical professions, such as nurses,
• physicians, medical technicians, or hospital
• · Treatment focuses on managing symptoms and
• improving quality of life.
• · A trusting relationship helps to ensure that
client’s stay
• with and receive care from one provider instead of
• “doctor shopping.”
• · SSRIs are commonly used for depression that
may
• accompany somatoform disorders.
• Assessment
• · The nurse must investigate physical health
status
• thoroughly to ensure there is no underlying
pathology
• requiring treatment. It is important not to dismiss
all
• future complaints because at any time the client
could
• develop a physical condition that would require
medical
• attention.
• · In many cases, the client’s appearance brightens
and
• they look much better as the assessment
interview
• begins because they have the nurse’s undivided
• attention.
• · Client’s often have sleep pattern disturbances,
lack
• basic nutrition, and get no exercise.
• Nursing diagnoses
includes learning problem solving methods.
The nurse should help the client role play the
• above situations.
• · Ineffective denial
• o The client will verbally express emotional
feelings
• The nurse should not attempt to confront
• clients about somatic symptoms or attempt
• to tell them that these symptoms are not
• “real.”
• Encourage the client to write in a daily
• journal
• Limiting the time that clients can focus on
• physical complaints alone may be necessary.
• The nurse may have to explain to the family
• about primary and secondary gains; this will
• encourage relatives to stop reinforcing the
• “sick role.”
• · Impaired social interactions
• o The client will follow an established daily routine or even that one exists.
• The nurse must help the client to establish
• this that includes improved health behaviors.
• The challenge for the nurse is to validate the
• client’s feelings while encouraging him to
• pump through heart, also due to excessive
participate in activities.
• The nurse should help the client plan social
• contact with others, what to talk about (other
• than the client’s complaints), and can
• · Fatigue
• · Pain
Eating disorders
The distinguishing factor of anorexia includes an earlier
age
of onset and below-normal body weight; the person fails to
recognize the eating behavior as a problem. Clients with
bulimia have a latter age at onset and a near-normal body
weight. They usually are ashamed and embarrassed by the
eating disorder.
Eating disorders appear to be equally common among
Hispanic and white women and less common among
African
American and Asian women.
Anorexia Nervosa
· A life-threatening eating disorder characterized by the
client’s refusal or inability to maintain a minimally
normal body weight, intense fear of gaining weight or
becoming fat, significantly disturbed perception of the
shape or size of the body, and steadfast inability or
refusal to acknowledge the seriousness of the problem
· Has experienced amenorrhea for at least 3 consecutive
cycles
· Complaints of constipations and abdominal pain
· Hypotension, hypothermia, bradycardia
o Intravascular volume is decreased; less blood to
exercise
· Elevated BUN
o Normal levels: 10-20 mg/dl
o Urea is formed in the liver and is the end product
 of protein metabolism.
o In anorexia, the body has already used fat for
energy; it is now breaking down muscles for
energy—the reason for the elevated BUN
· Decreased albumin
o Normal levels: 3.5-5 g/dl
o Measures amount of protein in the body; albumin
is a protein formed in the liver.
Albumin tests are a great indicator of nutritional
status
· Leukopenia and mild anemia
o Not enough food and nutrients to replenish cells
· Has a preoccupation with food and food-related
activities
· Can be divided into 2 subgroups:
o Restricting subtype : lose weight primarily through
dieting, fasting, or excessively exercising.
o Binge eating and purging subtype : engage
regularly in binge eating followed by purging.
· Engage in unusual or ritualistic food behaviors
o Refusing to eat around others
o Cutting food into minute pieces
o Not allowing the food they eat to touch their lips
· Excessive exercise is common
· Diagnosed between 14 and 18 years of age
· Pleased with their ability to control their weight and
may express this.
· As the illness progresses, depression and lability in
mood become more apparent
· Isolate themselves
· Believe peers are jealous of their weight loss and
believe family and health care professionals are trying
to make them “fat and ugly”.
· Clients who use laxatives are at a greater risk for
medical complications.
· Autonomy may be difficult in families that are
overprotective or in with enmeshment (lack of clear
boundaries) exists. By losing weight, these clients have
some control in their lives.
· Have body image disturbance (page 409)
· Can be very difficult to treat because they are often
resistant, appear uninterested, and deny their
problems.
· Treatment:
o Focusing on weight restoration
o Nutritional rehabilitation
o Rehydration
Correction of electrolyte imbalances
o Severely malnourished individuals may require
TPN, tube feedings, or hyperalimentation to
receive adequate nutritional intake.
o Access to the bathroom is supervised to prevent
purging as clients begin to eat more food.
o Weight gain and adequate food intake are most
often the criteria for determining the effectiveness
of treatment.
o Amitriptyline (Elavil) and the antihistamine
cyproheptadine (Periactin) in high doses (up to
28mg/d) can promote weight gain in inpatients.
o Olanzapine (Zyprexa) has been used with success
because of both its antipsychotic effect (on bizarre
body image distortions) and associated weight
gain.
o Fluoxetine (Prozac) has shown some effectiveness
in preventing relapse in clients whose weight has
been partially or completely restored; close
monitoring is needed because weight loss can be a
side effect.
· Family members often describe clients with anorexia as
perfectionists with above average intelligence,
dependable, eager to please, and seeking approval
before their condition began.
· Clients with anorexia appear slow, lethargic, and
fatigued; they may appear emaciated, depending on
the amount of weight loss. May be slow to respond and
have difficulty deciding what to say.
· Reluctant to answer questions fully because they do not
want to acknowledge any problem.
· Often wear loose clothing in layers
· Seldom smile, laugh, or enjoy any attempts at humor
Bulimia Nervosa
· Characterized by recurrent episodes (at least twice a
week for 3 months) of binge eating followed by
inappropriate measures to avoid weight gain such as
purging (vomiting, laxatives, diuretics, enemas, or
emetics), fasting, or excessively exercising.
· Engaging in binge eating secretly
· Binging or purging episodes are often precipitated by
strong emotions and followed by guilt, remorse, shame,
or self-contempt.
· Recurrent vomiting destroys tooth enamel, has dental
caries and ragged or chipped teeth. Dentists are often
the first health care professionals to recognize this.
· Bulimia is typically diagnosed at 18 or 19.
· Clients with bulimia are aware that their eating
behavior is pathologic and go great lengths to hide it
from others.
· Clients with a co-morbid personality disorder tend to
have poorer outcomes than those without.
· Most are treated on an outpatient basis
· Antidepressants are more effective than the placebos in
reducing binge eating
· Clients are often focused on pleasing others and have a
history of impulsive behavior such as substance abuse
and shoplifting as well as anxiety, depression, and
personality disorders.
· May be underweight, overweight, but are generally
close to expected body weight for age and size
· Appear open and willing to talk; initially pleasant and
cheerful as though nothing is wrong
Nursing outcomes/interventions
Imbalanced Nutrition: Less than/More than body
requirements
· The client will establish adequate nutritional eating
Patterns
Implement and supervise the regimen for
nutritional rehabilitation
o A diet of 1200-1500 calories is ordered, with
gradual increases in calories until clients are
ingesting adequate amounts for height, activity
level, and growth needs.
Start slowly—will have massive diarrhea
o The client with anorexia may be critically
malnourished.
TPN through central line
Electrolyte balance
Tube feeds
o A liquid protein supplement is given to replace any
food not eaten to ensure consumption to ensure
total number of calories prescribed
o Must monitor meals and snacks and will sit at the
table during eating away from the other clients
A major goal is to first get them to the table
o Diet beverages and food substitutions may be
prohibited
o Specified time may be set for consuming each
meal and snack
o Discourage clients from performing food rituals
such as cutting food into tiny pieces or mixing
foods in unusual combinations
o Be alert for any attempts by client to hide or
discard food
o Must remain in view of staff for 1-2 hours to
ensure they do not vomit; access to bathrooms is
supervised.
o Client is weighed daily on awakening and after
they have emptied their bladder. Have the client
wear a hospital gown each time they are weighed;
they may attempt to place objects in their clothing
to give the appearance of weight gain.
o In bulimia, the clients should sit at a table in a
kitchen or dining room.
o Write out a grocery list, it is easier to follow a
nutritious eating plan
Ineffective coping
· The client will eliminate use of compensatory behaviors
such as excessive exercise and use of laxatives and
diuretics
· The client will demonstrate coping mechanisms not
related to food
· The client will verbalize feelings of guilt, anger, anxiety,
or an excessive need for control
o Help the client recognize emotions such as anxiety
or guilt by asking them to describe what they are
feeling; allow adequate time for response. Do not
ask “are you anxious? Sad?” because the client
may quickly agree rather than struggle for an
answer
o Encourage self-monitoring (page 414); a
behaviorcognitive
approach
Disturbed body image
· The client will verbalize acceptance of body image with
stable body weight
o Help clients identify areas of personal strength
that are not food-related broadens clients’
perceptions of themselves
TIC disorders
· Sudden, rapid, recurrent, non-rhythmic motor
movement or vocalization
· Stress and fatigue exacerbates tics
· Treatment: Risperadol and Zyprexia
· Complex vocal tics
o Coprolalia : Use of socially unacceptable words,
often obscene
o Palilalia : Repeating own sounds or words
o Echolalia : Repeating the last heard sound, word, or
phrase
Autistic disorder
· Most prevalent in boys; identified no later than 3-years
of age
· Child has little eye contact, few facial expression,
doesn’t use gestures to communicate
· Does not relate to parents or peers, lacks spontaneous
enjoyment, apparent absence of mood and emotional
affect, can not be engaged in play or make believe
· Repetitive motor behaviors such as hand-flapping, body
twisting, or head banging
· May improve as child acquires language skills
· Short term impatient therapy is used when behaviors
such as head banging or tantrums are out of control
o Haldol or Risperadol may be effective (prn, of
course)
· Goals of treatment:
o Reduce behavioral symptoms
o Promotes learning and development
o Language skills development