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

Tension Pneumothorax air enters plural space with @ inspiration & cant 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
2
3
4
5
6
7

Sudden sharp chest pain

Dyspnea
Cyanosis
Diminished breath sound of affected lung
Cool moist skin
Mild restlessness/ apprehension
Resonance to hyper resonance

Diagnosis:
1
2

ABG pO2 decrease

CXR confirms pneumothorax

Nursing Mgt:
1
2
3
4

Endotracheal intubation
Thoracenthesis
Meds Morphine SO4
Anti microbial agents
Assist in test tube thoracotomy

Nursing Mgt if pt is on CPT attached to H2O drainage

1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage clamp
c.) Extra bottle
4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) 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
2
3

If (-) fluctuations
(+) Breath sounds
CXR full expansion of lungs

Nursing Mgt of removal of chest tube

1
2
3
-

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

Flail Chest

Sucking Chest Wound

Pneumothorax

Affected side
goes down
during
inspiration and
up during
expiration

(Sucking Open
Pneumothorax)

Collapse of lung due to

alteration of air in
intrapleural space

Sucking sound with

respiration
Pain
Decreased breath
sounds
Anxiety

Dyspnea
Pleuritic pain
Restricted movement
on affected side
Decreased/absent
breath sounds
Cough
Hypotension

Implementatio
n
Monitor for
shock
Humidified
oxygen
Thoracentesis
(aspiration of
fluid from
pleural space)
Chest Tubes

Tracheostomy Tube Cuff

Purposeprevents aspiration of fluids
Inflated
o During continuous mechanical ventilation
o During and after eating
o During and 1 hour after tube feeding
2

When patient cannot handle oral secretions

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 delivered
o Provides cooled, humidified air
o Check oxygen concentration with oxygen analyzer q4 hours
o Clean humidity jar and fill with distilled water daily
o Cover patient with light blanket and cap for head
o Raise side rails completely
o Change linen frequently
o Monitor patients 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:

Complications of Chest Tubes:

Instruct patient to do
valsalva maneuver
Clamp chest tube
Remove quickly
Occlusive dressing
applied

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
3

 Measure at highest level of fluctuation

After insertion
o Dry, sterile dressing
o Change dressing, IV fluids, manometer, tubing q24 hours
o Instruct patient to hold breath when inserted, withdrawn, tubing changed
o Check and secure all connections
Normal reading3-11 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)
5

- decreased peripheral pulses

- chest pain
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
6

-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
- 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
7

Complications ...
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
Pericardium

Parietal layer

Pericardial

Visceral layer

Fluid prevent
Friction rub
Layer
1 Epicardium outermost
2 Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3 Endocardium innermost layer
Chambers
1 Upper collecting/ receiving chamber - Atria
2 Lower pumping/ contracting chamber - Ventricles
Valves
1

Atrioventricular valves - Tricuspid & mitral valve

Closure of AV valves gives rise to 1 st heart sound or S1 or lub

Semi lunar valve

a Pulmonic
b Aortic
Closure 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

Atrioventicular node (AV node or Tawara node)

Loc inter atrial septum
Delay of electric impulse to allow ventricular filling

Bundle of His location interventricular septum

Rt main Bundle Branch
Lt main Bundle Branch

Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions
9

Complete heart block insertion of pacemaker at Bundle Branch

Metal Pace Maker change q3 5 yo
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 male
2 Black race
3 Hyperlipidemia
4 Smoking
5 HPN
6 DM
7 Oral contraceptive- prolonged use
8 Sedentary lifestyle
9 Obesity
10 Hypothyroidism
Signs & Symptoms
1
2
3
4
5

Chest pain
Dyspnea
Tachycardia
Palpitations
Diaphoresis

Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
10

Obj:
1 To revascularize the myocardium
2 To prevent angina
3. Increase survival rate
PTCA done to pt with single occluded vessel .
Multiple occluded vessels - CABG
Nsg Mgt Before CABG
1
2
3

Deep breathing cough exercises

Use of incentive spirometer
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 male
2 African American
3 hyperlipidemia
4 smoking
5 HPN
6 DM
7 oral contraceptive - prolonged
8 sedentary lifestyle
9 obesity
10.hypothyroidism
Precipitating factors
4 Es
1
2
3

Excessive physical exertion

Exposure to cold environment - Vasoconstriction
Extreme emotional response
4.
Excessive intake of food saturated fats.

Signs & Symptoms

1
2

Initial symptoms Levines sign hand clutching of chest

Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT

3 Dyspnea
4 Tachycardia
5 Palpitation
6 Diaphoresis

11

Diagnosis
1. History taking & PE
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
2

Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
Monitor S/E:
o orthostatic hypotension dec bp
o transient headache
o dizziness
3 Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
o avoid placing it near hairy areas-will dec drug absorption
o avoid rotating transdermal patches- will dec drug absorption
o 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

12

7.)

HT: Discharge planning:

Avoid precipitating factors 4 Es

Prevent complications MI
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
2

Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery

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

sex male
black raise
hyperlipidemia
smoking
HPN
DM
oral contraceptive prolonged
sedentary lifestyle
obesity
hypothyroidism

1. chest pain excruciating, vice like, visceral

pain located substernal or precodial area
(rare)

1. cardiac enzymes
a.) CPK MB Creatinine
Phosphokinase

- radiates back, arm, shoulders, axilla, jaw &

abd muscles.

b.) LDH lactic acid dehydrogenase

- not usually relived by rest r NTG

c.) SGPT (ALT) Serum Glutanic

Pyruvate Transaminase- increased

2. dyspnea
3. erthermia

d.) SGOT (AST) Serum Glutamic

Oxalo-acetic - increased

4. initial increase in BP

2. Troponin test increase

5. mild restlessness & apprehensions

3. ECG tracing ST segment

increase,

6. occasional findings
a.) split S1 & S2
b.) pericardial friction rub

widening or QRS complexes means

arrhythmia in MI indicating PVC

c.) rales /crackles

4. serum cholesterol & uric acid increase

d.) S4 (atrial gallop)

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
13

a.) Bedside commode

4. Avoid Valsalva maneuver
5. Semi fowler
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. Dresslers 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

14

1. Streptokinase
2. Urokinase
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.

15

CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
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
2
3
4
5
6
7
8
9
10
11
12
13

Dyspnea
Orthopnea (Diff of breathing sitting pos platypnea)
Paroxysmal nocturnal dysnea PNO- nalulunod
Productive cough with blood tinged sputum
Frothy salivation (from lungs)
Cyanosis
Rales/ crackles due to fluid
Bronchial wheezing
PMI displaced lateral due cardiomegaly
Pulsus alternons weak-strong pulse
Anorexia & general body malaise
S3 ventricular gallop

1
2

CXR cardiomegaly
PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure

Dx

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
16

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

CVP indicates fluid or hydration status
Increase CVP decrease flow rate of IV
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
2
3
4
5

90% - tricuspid stenosis

COPD
Pulmonary embolism
Pulmonic stenosis
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 cardiomegaly
2. 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
17

Nsg mgt: Increase force of myocardial contraction = increase CO

3 6L of CO
1. Administer meds:
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

18

Digoxin ( Lanoxin) 0.5 2.0 ng/mL

Digitalis toxicity includes..
N - nausea
A - anorexia
V - vomiting
D - diarrhea
A - 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
19

LDL: <130 mg/dL

HDL: 30 to 70 mg/dL
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
20

Hypokalemia Assessments

Hypokalemia Implementations

K+ < 3.5 mEq/L

Muscle weakness
Paresthesias
Dysrhythmias
Increased sensitivity to digitalis

Hyperkalemia Assessments

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

Hyponatremia Assessments

Na+ < 135 mEq/L

Nausea
Muscle cramps
Confusion
Increased ICP

Hypernatremia Assessments

Na+ >145 mEq/L

Disorientation, delusion, hallucinations
Thirsty, dry, swollen tongue
Sticky mucous membranes
Hypotension
Tachycardia

Hypocalcemia Assessments

Ca+ < 4.5 mEq/L

Tetany
Positive Trousseaus sign
Positive Chvosteks sign
Seizures
Confusion
Irritability, paresthesias

Potassium Supplements
Dont give > 40 mEq/L into peripheral IV or without
cardiac monitor
Increase dietary intake oranges, apricots, beans,
potatoes, carrots, celery, raisins
Hyperkalemia Implementations

Restrict oral intake

Kayexalate
Calcium Gluconate and Sodium Bircarbonate
IV
Peritoneal or hemodialysis
Diuretics

Hyponatremia Implementations

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

Hypernatremia Assessments

I&O
Daily Weight
Give hypotonic solutions: 0.45% NaCl or 5%
Dextrose in water IV

Hypocalcemia Implementations

Oral calcium supplements with orange

(maximizes absorption)
Calcium gluconate IV
Seizure precautions
Meet safety needs

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Hypercalcemia Assessments

Ca+> 5.2 mEq/L

Sedative effects on CNS
Muscle weakness, lack of coordination
Constipation, abdominal pain
Depressed deep tendon reflexes
Dysrhythmias

Hypomagnesemia Assessments

Mg+< 1.5 mEq/L

Neuromuscular irritability
Tremors
Seizures
Tetany
Confusion
Dysphagia

Hypermagnesemia Assessments
Mg + > 2.5 mEq/L
Hypotension
Depressed cardiac impulse
transmission
Absent deep tendon reflexes
Shallow respirations

Hypercalcemia Implementations

0.4% NaCl or 0.9% NaCl IV

Encourage fluids (acidic drinks: cranberry juice)
Diuretics
Calcitonin
Mobilize patient
Surgery for hyperparathyroidism

Hypomagnesemia Implementations

Monitor cardiac rhythm and reflexes

Test ability to swallow
Seizure precautions
Increase oral intakegreen vegetables, nuts,
bananas, oranges, peanut butter, chocolate

Hypermagnesemia Implementations
Discontinue oral and IV magnesium
Monitor respirations, cardiac rhythm, reflexes
IV Calcium to antagonize cardiac depressant
activity (helps to stimulate heart)

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