PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.

Types:

1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.Eg. rupture of bleb (alveoli filled sacs) in pt with inflamed lung conditions

Eg. open pneumothorax – air enters pleural space through an opening in chest wall

-Stab/ gun shot wound

2. Tension Pneumothorax – air enters plural space with @ inspiration & can’t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.Eg. flail chest – “paradoxical breathing”

Predisposing factors:

1.Chest trauma

2.Inflammatory lung conditions

3.Tumor

S/Sx:

1. Sudden sharp chest pain 2. Dyspnea3. Cyanosis4. Diminished breath sound of affected lung5. Cool moist skin6. Mild restlessness/ apprehension7. Resonance to hyper resonance

Diagnosis:

1. ABG – pO2 decrease –2. CXR – confirms pneumothorax

Nursing Mgt:

1. Endotracheal intubation2. Thoracenthesis3. Meds – Morphine SO4- Anti microbial agents4. Assist in test tube thoracotomy

Nursing Mgt if pt is on CPT attached to H2O drainage

1. Maintain strict aseptic technique2. DBE3. At bedside

a.) Petroleum gauze pad if dislodged Hemostanb.) If with air leakage – clamp c.) Extra bottle

4. Meds – Morphine SO4Antimicrobial

5. Monitor & assess for oscillation fluctuations or bubblinga.) If (+) to intermittent bubbling means normal or intact

1

- H2O rises upon inspiration

- H2o goes down upon expiration

b.) If (+) to continuous, remittent bubbling

1. Check for air leakage

2. Clamp towards chest tube

3. Notify MD

c.) If (-) to bubbling

1. Check for loop, clots, and kink

2. Milk towards H2O seal

3. Indicates re-expansion of lungs

When will MD remove chest tube:

1. If (-) fluctuations2. (+) Breath sounds3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube

1. DBE2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 3. Apply vaselinated air occlusive dressing - Maintain dressing dry & intact

Flail Chest

Affected side goes down during inspiration and up during expiration

Sucking Chest Wound

(Sucking Open Pneumothorax)

Sucking sound with respiration

Pain Decreased breath

sounds Anxiety

Pneumothorax

Collapse of lung due to alteration of air in intrapleural space

Dyspnea Pleuritic pain Restricted movement

on affected side Decreased/absent

breath sounds Cough Hypotension

Implementation

Monitor for shock

Humidified oxygen

Thoracentesis (aspiration of fluid from pleural space)

Chest Tubes

Tracheostomy Tube Cuff

Purpose—prevents aspiration of fluids Inflated

o During continuous mechanical ventilationo During and after eatingo During and 1 hour after tube feedingo When patient cannot handle oral secretions

2

Oxygen Administration: assess patency of nostril, apply jelly

Face mask: 5-10 l/min (40-60%) Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during inspiration Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during inspiration Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed concentrations, keep tubing free of kinks Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty condensation from tubing’ keep water container full Croupette or oxygen tent:

o Difficulty to measure amount of oxygen deliveredo Provides cooled, humidified airo Check oxygen concentration with oxygen analyzer q4 hourso Clean humidity jar and fill with distilled water dailyo Cover patient with light blanket and cap for heado Raise side rails completelyo Change linen frequentlyo Monitor patient’s temperature

Chest Tubes Implementations

Use to utilize negative pressure in lungs

Fill water-seal chamber with sterile water to 2 cm

Fill suction control chamber with sterile water to 20 cm

Maintain system below level of insertion

Clamp only momentarily to check for air leaks

Ok to milk tubing towards drainage

Observe for fluctuation in water-seal chamber

Encourage patient to change position frequently

Chest Tube Removal:

Instruct patient to do valsalva maneuver

Clamp chest tube Remove quickly Occlusive dressing

applied

Complications of Chest Tubes:

Constant bubbling in water-seal chamber=air leak

Tube becomes dislodged from patient, apply dressing tented on one side

Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert

Tube becomes disconnected from drainage system, immerse end in 2 cm of sterile water

CVP: measures blood volume and efficiency of cardiac work; tells us right side of heart able to manage fluid

“0” on mamometer at level of right atrium at midaxilliary line Measure with patient flat in bed Open stopcock and fill manometer to 18-20 cm Turn stopcock, fluid goes to patient Level of fluid fluctuates with respirations Measure at highest level of fluctuation After insertion

o Dry, sterile dressingo Change dressing, IV fluids, manometer, tubing q24 hours

3

o Instruct patient to hold breath when inserted, withdrawn, tubing changedo Check and secure all connections

Normal reading—3-11 cm water Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician) Lowered<3, hypovolemia Chest tray at bedside

Oxygen Toxicity

S/S - nonproductive cough, substernal pain, nasal stuffiness and hypoventilation

Treatment :

- use of CPAP, BiPAP or PEEP

- give the least amount of O2 necessary to maintain SaO2 levels

- use Venturi Mask when client needs precise amount of O2 delivered such as those with COPD

Types of Ventilator alarms ...

Volume alarm: Ventilator (L) - alarm indicate low exhaled volume d/t disconnection, cuff leak, and tube displacement

Pressure alarm: Ventilator (H) - alarm indicate excess secretions, client biting the tubing, kinks and client coughing

Apnea alarm: Ventilator indicate that the ventilator does not detect spontaneous respiration

Hemodynamic Readings ** the intravascular volume in older adult clients is often reduced; therefore, the nurse should anticipate lower hemodynamic readings, particularly if dehydration is a complication

ELEVATED results are indicative of HF and pulmonary problems

Central Venous Pressure (CVP) 1-8 mmHg

Pulmonary Artery Systolic (PAS) 15-26 mmHg

Pulmonary Artery Diastolic (PAD) 5 - 15 mmHg

Pulmonary ARtery Wedge Pressure (PAWP) 4-12 mmHg

Cardiac Output (CO) 4-6L/min

Mixed Venous Oxygen Saturation (SvO2) 60% - 80%

Arterial/Pulmonary Artery Line Insertion - Pace the client in supine or trendelenburge position

- level transducer with phlebostatic axis (4th intercostal space, mid-axillary line)

- zero system with atmospheric pressure

- hemodynamic pressure lines must be calibrated to read atmospheric pressure as zero, and the transducer should be positioned at the right atrium

** HOB when obtaining readings should be 15-30 deg

4

Angina - Warning sign of an impending acute MI

- described as: TIGHT, SQUEEZING, heavy pressure, or constricting feeling in the chest. the pain can radiate to the jaw, neck, or arm.

Types of Angina - stable angina (exertional): occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat)

- unstable angina (preinfarction angina): occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time

- variant angina (Prinzmetal's angina): dt a coronary artery spasm, often occurring during periods of rest.

** Pain unrelieved by rest or nitroglycerin and lasting more than 15 in differentiates an MI from angina

Angina vs MI Angina

- precipated by exertion or stress

- relieved by rest or nitroglycerin

- sx last <15 min

- not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis

MI - con occur w/o cause, often in the morning after the rest

- relived only by opioids (MORPHINE)

- sx last > 30 min

- associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis

Lab tests - myoglobin: levels no longer evident after 24 hrs

- Creatnine kinase MB: levels n longer evident after 3 days

- Troponin I: levels NO longer evident after 7 days

- Troponin T: levels no longer evident after 14-21 days

Heart Failure/ Cardiogenic shock - injury to LEFT ventricle can lead to decreased CO and HF

- progressive HF leads to cardiogenic shock

S/S

- hypotension

- tachycardia

- altered level of consciousness

- respiratory distress (crackles/ tachypnea)

- decreased peripheral pulses

- chest pain

5

s/s: Left sided heart failure - S3 gallop

- orthopnea

- oliguria

- frothy sputum

- displaced apical pulse

s/s: right sided heart failure - jugular vein distension

- ascending dependent edema

- polyuria at rest

- abdominal distension (ascites

- weight gain

- hepatomegaly and tenderness

Lab tests: HF - Human B-type natriuretic peptides (hBNP): Elevated in HF; used to differentiate dyspnea rt HF vs respiratory problem

- <100 pg/mL = no HF

- 100 to 300 pg/mL = HF is present

- > 300 pg/mL = mild HF

- >600 pg/mL = moderate HF

- >900 pg/mL - severe HF

Diuretics - Loop: Lasix and Bumex

administer Lasix no faster than 20 mg/min Thiazide: hydrochlorothiazide Potassium sparing diuretics: spironolactone (aldactone) Afterload reducing agents - ACE inhibitors: "prils" Angiotensin receptor II blockers: losartan (Cozaar) contraindicated for clients who have renal deficiency monitor for HYPOTENSION

Client Education

notify MD if sense of taste decrease notify MD if swelling of the face or extremities occurs take BP 2 hrs after initial does to detect hypotension Inotropic agents- digoxin, duutamine, primacor Increase the contractility and thereby improve CO

Nx considerations

-digoxin: take apical pulse for 1 min; < 60/min hold the med and notify MD - monitor urine output client education - if pulse is irregular; hold meds and notify MD

6

- take digoxin dose same time each day - DO NOT take digoxin with antacids; separate by 2 hrs apart - toxicity signs: fatigue, muscle weakness, confusion, loss of appetite. Therapeutic range: digoxin 0.8 to 2 ng/mL

Toxicity:

decreased potassium level decreased apical rate < 60 blurred vision dysrhythmia leg cramps anorexia altered mental status

Vasodilators

Nitroglycerine (Nitrostat) and isosorbide mononitrate (Imdur): prevent coronary artery vasospasms and reduce preload and afterload, decreasing myocardial O2 demand.

Nx Considerations

caution with other antihypertensive medications can cause ORTHOSTATIC HYPOTENSION

Client Education

HEADACHE is common side effects Encourage the client to site and lie down slowly

hBNPs nesiritide (Natrecor): used to treat acute HF by casing natriuresis (loss of sodium and vasodilation)

Nx Considerations

can cause HYPOTENSION BNP levels will increased while on this med

Client Education

client can be asymptomatic with low BP

Pulmonary Edema

Nx Actions

restrict fluid intake administer rapid acting diuretics (lasix/bumex), vasodilators (nitroglycerin), inotropic agents (digoxin),

antihypertensive ("pril" and "olol") Client education notify md if gain of more than 2lb in a day or 5 lb in a week diet: low sodium and fluid restriction report: SOB, swelling of feet or ankles, or angina

Complications ...

7

Acute Pulmonary edema s/s

tachycardia ascending fluid level within the lungs (CRACKLES, productive cough, blood tinged sputum)

Emergency response

position in high-Fowler's Administer O2, positive airway pressure, and/or intubation and mechanical ventilation IV morphine IV Lasix ** effectiveness = diuresis, reduction in respiratory distress, improved lung sounds, and adequate O2

Cardiovascular System

8

Pericardium

Parietal layer Pericardial Visceral layer

Fluid – prevent

Friction rub

Layer

1. Epicardium – outermost2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock3. Endocardium – innermost layer

Chambers

1. Upper – collecting/ receiving chamber - Atria2. Lower – pumping/ contracting chamber - Ventricles

Valves

1. Atrioventricular valves - Tricuspid & mitral valve Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”

2. Semi lunar valvea.) Pulmonicb.) AorticClosure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”

Extra heart Sound

S3 – ventricular Gallop – CHF

S4 – atrial gallop – MI, HPN

Heart conduction system

1. Sino atrial node (SA node) (or Keith-Flock node) Loc – junction of SVC & Rt atrium

Fx- primary pace maker of heart

-Initiates electric impulse of 60 – 100 bpm

2. Atrioventicular node (AV node or Tawara node)Loc – inter atrial septum

Delay of electric impulse to allow ventricular filling

3. Bundle of His – location interventricular septumRt main Bundle Branch

Lt main Bundle Branch

4. Purkenjie Fiber Loc- walls of ventricles-- Ventricular contractions

Complete heart block – insertion of pacemaker at Bundle Branch

Metal – Pace Maker – change q3 – 5 yo

9

Prolonged PR – atrial fib T wave inversion – MI

ST segment depression – angina widening QRS – arrhythmia

ST – elev – MI

CAD – coronary artery Disease or Ischemic Heart Disease (IHD)

Atherosclerosis – Myocardial injury

Angina Pectoris – Myocardial ischemia

MI- myocardial necrosis

ATHEROSCLEROSIS ARTEROSCLEROSIS

- Hardening or artery due to fat/ lipid deposits at tunica intima.

- Narrowing or artery due to calcium & CHON deposits at tunica media.

ATHEROSCLEROSIS

Predisposing Factor

1. Sex – male2. Black race3. Hyperlipidemia4. Smoking5. HPN6. DM7. Oral contraceptive- prolonged use8. Sedentary lifestyle9. Obesity10. Hypothyroidism

Signs & Symptoms

1. Chest pain2. Dyspnea3. Tachycardia4. Palpitations5. Diaphoresis

Treatment

P – percutaneous

T – tansluminar

C – coronary

A – angioplasty

Obj:

1. To revascularize the myocardium2. To prevent angina

10

3. Increase survival rate

PTCA – done to pt with single occluded vessel .

Multiple occluded vessels - CABG

Nsg Mgt Before CABG

1. Deep breathing cough exercises2. Use of incentive spirometer3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting from temp myocardial ischemia.

Predisposing Factor:

1.sex – male2.African American3.hyperlipidemia4.smoking5.HPN6.DM7.oral contraceptive - prolonged8.sedentary lifestyle9.obesity

10.hypothyroidism

Precipitating factors

4 E’s

1. Excessive physical exertion2. Exposure to cold environment - Vasoconstriction3. Extreme emotional response

4. Excessive intake of food – saturated fats.

Signs & Symptoms

1. Initial symptoms – Levine’s sign – hand clutching of chest 2. Chest pain – sharp, stabbing excruciating pain. Location – substernal

-radiates back, shoulders, axilla, arms & jaw muscles

-relieve by rest or NGT

3. Dyspnea 4. Tachycardia5. Palpitation6. Diaphoresis

Diagnosis

1. History taking & PE

11

2. ECG – ST segment depression

3. Stress test – treadmill = abnormal ECG

4. Serum cholesterol & uric acid - increase.

Nursing Management

1.) Enforce CBR

2.) Administer meds

NTG – small doses – venodilator

Large dose – vasodilator

1st dose NTG – give 3 – 5 min

2nd dose NTG – 3 – 5 min

3rd & last dose – 3 – 5 min

Still painful after 3rd dose – notify doc. MI!

Medication:

A. NTG- Nsg Mgt:

1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.2. Monitor S/E:

o orthostatic hypotension – dec bpo transient headacheo dizziness

3. Rise slowly from sitting position4. Assist in ambulation.

5. If giving NTG via patch:

o avoid placing it near hairy areas-will dec drug absorptiono avoid rotating transdermal patches- will dec drug absorptiono avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in

patch

B. Beta blockers – propranolol

C. ACE inhibitors – captopril

D. Ca antagonist - Nefedipine

3.) Administer O2 inhalation

4.) Semi-fowler

5.) Diet- Decrease Na and saturated fats

6.) Monitor VS, I&O, ECG

7.) HT: Discharge planning:

Avoid precipitating factors – 4 E’s Prevent complications – MI

12

Take meds before physical exertion-to achieve maximum therapeutic effect of drug Importance of follow-up care.

MI – MYOCARDIAL INFARCTION – heart attack – terminal stage of CAD

- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery2. Sub-endocardial MI – mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI – 48 to 72h

- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam

1.sex – male2.black raise3.hyperlipidemia4.smoking5.HPN6.DM7.oral contraceptive

prolonged8.sedentary lifestyle9.obesity10. hypothyroidism

1. chest pain – excruciating, vice like, visceral pain located substernal or precodial area (rare)

- radiates back, arm, shoulders, axilla, jaw & abd muscles.

- not usually relived by rest r NTG

2. dyspnea

3. erthermia

4. initial increase in BP

5. mild restlessness & apprehensions

6. occasional findings

a.) split S1 & S2

b.) pericardial friction rub

c.) rales /crackles

d.) S4 (atrial gallop)

1. cardiac enzymes

a.) CPK – MB – Creatinine Phosphokinase

b.) LDH – lactic acid dehydrogenase

c.) SGPT – (ALT) – Serum Glutanic Pyruvate Transaminase- increased

d.) SGOT (AST) – Serum Glutamic Oxalo-acetic - increased

2. Troponin test – increase

3. ECG tracing – ST segment increase,

widening or QRS complexes – means arrhythmia in MI indicating PVC

4. serum cholesterol & uric acid - increase

5. CBC – increase WBC

Nursing Management

1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.

2. Administer O2 inhalation – low inflow (CHF-increase inflow)

3. Enforce CBR without BP

a.) Bedside commode

4. Avoid Valsalva maneuver

5. Semi fowler

13

6. General liquid to soft diet – decrease Na, saturated fat, caffeine

7. Monitor VS, I&O & ECG tracings

8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation.

9. Assist in surgical; CABAG

10. Provide pt HT

a.) Avoid modifiable risk factors

b.) Prevent complications:

1. Arrhythmias – PVC

2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria

3. thrombophlebitis - deep vein

4. CHF – left sided

5. Dressler’s syndrome – post MI syndrome

-Resistant to medications

-Administer 150,000 – 450,000 units of streptokinase

c.) Strict compliance to meds

- Vasodilators

1. NTG

2. Isordil

- Antiarrythmic

1. Lydocaine blocks release of norepenephrine

2. Brithylium

- Beta-blockers – “lol”

1. Propanolol (inderal)

- ACE inhibitors - pril

1. Captopril – (enalapril)

- Ca – antagonist

1. Nifedipine

- Thrombolitics or fibrinolytics– to dissolve clots/ thrombus

1. Streptokinase

2. Urokinase

14

3. Tissue plasminogen adjusting factor

Monitor for bleeding:

- Anticoagulants

1. Heparin 2. Coumadin – delayed reaction 2 – 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote- Protamine sulfate antidote Vitamin- K

- Anti platelet (aspirin)

d.) Resume ADL – sex/ activity – 4 to 6 weeks

Post-cardiac rehab

1.)Sex as an appetizer rather then dessert –

Before meals not after, due after meals increase metabolism – heart is pumping hard after meals.

2.) Position – non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.

e.) Diet – decrease Na, Saturated fats, and caffeine

f.) Follow up care.

CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.

- Backflow

15

1.) Left sided heart failure:

Predisposing factors:

1.) 90% mitral valve stenosis – due RHD, aging

RHD affects mitral valve – streptococcal infection

Dx: - Aso titer – anti streptolysine O > 300 total units

- Steroids

- Penicillin

- Aspirin

Complication: RS-CHF

Aging – degeneration / calcification of mitral valve

Ischemic heart disease

HPN, MI, Aortic stenosis

S/Sx

Pulmonary congestion/ Edema

1. Dyspnea2. Orthopnea (Diff of breathing sitting pos – platypnea)3. Paroxysmal nocturnal dysnea – PNO- nalulunod4. Productive cough with blood tinged sputum5. Frothy salivation (from lungs)6. Cyanosis7. Rales/ crackles – due to fluid8. Bronchial wheezing 9. PMI – displaced lateral – due cardiomegaly10. Pulsus alternons – weak-strong pulse11. Anorexia & general body malaise12. S3 – ventricular gallop13.

Dx

1. CXR – cardiomegaly2. PAP – Pulmonary Arterial Pressure

PCWP – Pulmonary CapillaryWedge Pressure

PAP – measures pressure of R ventricle. Indicates cardiac status.

PCWP – measures end systolic/ diastolic pressure

PAP & PCWP:

Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU

(Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set

CVP – indicates fluid or hydration status

Increase CVP – decrease flow rate of IV

16

Decrease CVP – increase flow rate of IV

3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy

4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor

1. 90% - tricuspid stenosis 2. COPD3. Pulmonary embolism4. Pulmonic stenosis5. Left sided heart failure

S/Sx

Venous congestion

- Neck or jugular vein distension- Pitting edema- Ascites- Wt gain- Hepatomegalo/ splenomegaly- Jaundice- Pruritus- Esophageal varies- Anorexia, gen body malaise

Diagnosis:

1. CXR – cardiomegaly2. CVP – measures the pressure at R atrium

Normal: 4 to 10 cm of water

Increase CVP > 10 – hypervolemia

Decrease CVP < 4 – hypovolemia

Flat on bed – post of pt when giving CVP

Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote ventricular filling.

3. Echocardiography – enlarged heart chamber / cardiomyopathy

4.Liver enzyme

SGPT ( ALT)

SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO

3 – 6L of CO

1. Administer meds:

17

Tx for LSHF: M – morphine SO4 to induce vasodilatation

A – aminophylline & decrease anxiety

D – digitalis (digoxin)

D - diuretics

O - oxygen

G - gases

a.) Cardiac glycosides (Increase myocardial = increase CO) - Digoxin / Antidote: digibind

b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs

c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine

d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety

e.) Vasodilators – NTG

f.) Anti-arrythmics – Lidocaine

2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula

3. High fowlers

4. Restrict Na!

5. Provide meticulous skin care

6. Weigh Pt daily. Assess for pitting edema. Measure abdominal girth daily & notify MD

7. Monitor V/S, I&O, breath sounds

8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return

9. Diet – decrease salt, fats & caffeine

10. HT:

a) Complications :shock

Arrhythmia

Thrombophlebitis

MI

Cor Pulmonale – RT ventricular hypertrophy

c.) Dietary modifications

Digoxin ( Lanoxin) 0.5 – 2.0 ng/mL

18

Digitalis toxicity includes.. N - nauseaA - anorexiaV - vomitingD - diarrheaA - abdominal pain

Digitalis toxicity is the result of the body accumulating more digitalis than it can tolerate at that time. Patient will complain visual change in color, and loss of appetite

The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.

Normal PCWP is 8-13. Readings of 18-20 are considered high.

First sign of PE (pulmonary embolism) is sudden chest pain, followed by dyspnea and tachypnea.

High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure.

Pulmonary sarcoidosis leads to right sided heart failure.

Serum Amylase: normal (25-151 units/dL)

Serum Ammonia: normal (35 to 65 mcg/dL)

Albumin level: normal (3.4 to 5 g/dL)

Serum Osmolality: normal (285 to 295 mOsm/kg) - high value indicates dehydration

Safe Suction Range: normal [Infant] 50-95 mm Hg

[Child] 95-115 mm Hg

[Adult]100-120 mm Hg)

Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid

ELECTROLYTES

Potassium: 3.5-5.0 mEq/L

Sodium: 135-145 mEq/L

Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL

Magnesium: 1.5-2.5 mEq/L

Chloride: 96-107 mEq/L

Phosphorus: 2.7 to 4.5 mg/dL

Cholesterol: 140 to 199 mg/dL

LDL: <130 mg/dL

HDL: 30 to 70 mg/dL

19

Triglycerides: <200 mg/dL

Serum creatinine: 0.6 to 1.3 mg/dL

BUN: 9-25 mg/dL

Normal CK is 26-174 U/L

Troponin I value: normal (<0.6 ng/mL)

Troponin T >0.1 to 0.2 ng/mL = MI

COAGULATION STUDIES

Partial Thromboplastin Time (aPTT): normal (20-36 seconds) therapeutic 1.5-2.5

Prothrombin Time: normal (Male: 9.6-11.8 seconds) (Female: 9.5-11.3 seconds)

International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy

3.0 – 4.5 for high-dose Coumadin therapy

Clotting time: 8 – 15 minutes

Platelet count: 150,000 to 400,000 cells/Ul

Bleeding time: 2.5 to 8 minutes

SERUM GASTROINTESTINAL STUDIES

Albumin: 3.4 to 5 g/dL

Cholesterol: 120 – 200mg/dL

Lipase: 31 -186 U/L

Lipids: 400 – 800 mg/dL

Triclycerides: Normal range: 10 – 190 mg/dL

Borderline high: 200 – 400 mg/dL

High: 400 – 1000mg/dL

Very high: greater than 1000mg.dL

Protien: 6.0 – 8.0 g/L

RENAL FUNCTION TEST

Creatinine: 0.6 – 1.3 mg/dL

Blood urea nitrogen (BUN): 5 – 20 mg/dL

Hypokalemia Assessments Hypokalemia Implementations

20

K+ < 3.5 mEq/L Muscle weakness Paresthesias Dysrhythmias Increased sensitivity to digitalis

Potassium Supplements Don’t give > 40 mEq/L into peripheral IV or without

cardiac monitor Increase dietary intake – oranges, apricots, beans,

potatoes, carrots, celery, raisins

Hyperkalemia Assessments

K+ >5.0 mEq/L EKG changes Paralysis Diarrhea Nausea

Hyperkalemia Implementations

Restrict oral intake Kayexalate Calcium Gluconate and Sodium Bircarbonate

IV Peritoneal or hemodialysis Diuretics

Hyponatremia Assessments

Na+ < 135 mEq/L Nausea Muscle cramps Confusion Increased ICP

Hyponatremia Implementations

I & O Daily weight Increase oral intake of sodium rich foods Water restriction IV Lactated Ringer’s or 0.9% NaCL

Hypernatremia Assessments

Na+ >145 mEq/L Disorientation, delusion, hallucinations Thirsty, dry, swollen tongue Sticky mucous membranes Hypotension Tachycardia

Hypernatremia Assessments

I & O Daily Weight Give hypotonic solutions: 0.45% NaCl or 5%

Dextrose in water IV

Hypocalcemia Assessments

Ca+ < 4.5 mEq/L Tetany Positive Trousseau’s sign Positive Chvostek’s sign Seizures Confusion Irritability, paresthesias

Hypocalcemia Implementations

Oral calcium supplements with orange (maximizes absorption)

Calcium gluconate IV Seizure precautions Meet safety needs

Hypercalcemia Assessments

Ca+> 5.2 mEq/L Sedative effects on CNS Muscle weakness, lack of coordination

Hypercalcemia Implementations

0.4% NaCl or 0.9% NaCl IV Encourage fluids (acidic drinks: cranberry juice) Diuretics

21

Constipation, abdominal pain Depressed deep tendon reflexes Dysrhythmias

Calcitonin Mobilize patient Surgery for hyperparathyroidism

Hypomagnesemia Assessments

Mg+< 1.5 mEq/L Neuromuscular irritability Tremors Seizures Tetany Confusion Dysphagia

Hypomagnesemia Implementations

Monitor cardiac rhythm and reflexes Test ability to swallow Seizure precautions Increase oral intake—green vegetables, nuts,

bananas, oranges, peanut butter, chocolate

Hypermagnesemia Assessments

Mg + > 2.5 mEq/L Hypotension Depressed cardiac impulse

transmission Absent deep tendon reflexes Shallow respirations

Hypermagnesemia Implementations

Discontinue oral and IV magnesium Monitor respirations, cardiac rhythm, reflexes IV Calcium to antagonize cardiac depressant

activity (helps to stimulate heart)

22