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Live NCLEX
Review Day 1
Archer Review
© 2010- 2024 USMLE Galaxy LLC
 Part I -
Building Blocks
 archerreview.com | @archernclex

Instructors:
Lexie Garber | Lauren Korth | Rachel Taylor
Cait Capablanca | Elizabeth Daigger
Ema Muntean | Jennifer Bonner | Megan Miller
Allie Brooks

[email protected]
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 Where are you joining from
today?

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The NCLEX Test Plan
 Have you spent more time
memorizing or understanding
content during your NCLEX prep?

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 The Six Steps to Clinical Judgement
1. Recognize Cues

2. Analyze Cues

3. Prioritize Hypotheses

4. Generate Solutions

5. Take Actions

6. Evaluate Outcomes
 ABG
Interpretation
Get it right, every time!
 ABG Interpretation
ABG Interpretation
ABG Practice Questions
 How do you feel when it
comes to ABG questions?

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Acid Base Balance
● The body likes the pH to be 7.35-7.45
● If it gets higher or lower than this, it tries to bring it back into normal range!
○ This is called COMPENSATION
● There are two ways to compensate
○ Metabolic
■ Kidneys make bicarbonate - a base
● More bicarb → more alkalotic (pH goes HIGHER)
● Less bicarb → more acidotic (pH goes LOWER)
○ Respiratory
■ Lungs either retain, or blow off, CO2
● More CO2 → more acidotic (pH goes LOWER)
● Less CO2 → more alkalotic (pH goes HIGHER)
Normal Values
pH 7.35-7.45
Bicarbonate (HCO3) 22-28
CO2 35-45

Bicarb = BASE → metabolic

CO2 = ACID → respiratory
Step 1: Acidotic or Alkalotic?

Uncompensated acidosis Compensated Compensated Uncompensated alkalosis

acidosis alkalosis
<7.35 >7.45
7.35 -7.39 7.41 -7.45

7.4
perfect!
 Step 2: Respiratory or Metabolic?
CO2 problem = Respiratory HCO3 problem = Metabolic

Respiratory Respiratory Metabolic Metabolic

Acidosis Alkalosis Acidosis Alkalosis
Too much CO2 Not enough CO2 Not enough HCO3 Too much HCO3
• Hypoventilation • Hyperventilation • Renal Disease • Too much sodium
• Overdose • Panic attack • Loss of bicarb bicarb
• COPD • Diarrhea • Antacids
• Asthma • Vomiting
Step 3: Compensated or uncompensated?
Wait… partial or fully compensated?
Your client has the following arterial blood gas values.
What is the correct interpretation?

pH 7.58
CO2 35
HCO3 41
 What do you think the
answer is?

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poll while presenting.
 pH 7.58

CO2 35

HCO3 41

Step #1: Acidosis or alkalosis? →7.58 > 7.45 → Alkalosis

Step #2: Metabolic or respiratory? → The HCO3 is too high, causing a metabolic
alkalosis.

Step #3: Compensated or uncompensated? →The CO2 is normal - not helping!

Uncompensated.

UNCOMPENSATED METABOLIC ALKALOSIS

Knowledge Check!
Question 1
A client presents with the following ABG results.

What is the correct interpretation?

a. pH: 7.35

b. CO2: 40

c. HCO3: 23
 What do you think the
answer is?

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poll while presenting.
Answer: Normal
Step #1: Acidosis or alkalosis?

pH is normal.

Step #2: Respiratory or metabolic?

The CO2 is normal. The HCO3 is normal.

Step #3: Compensation?

Not needed…. Everything is normal!

Question 2
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.23

b. CO2: 67

c. HCO3: 28
 What do you think the
answer is?

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poll while presenting.
Answer: Uncompensated Respiratory Acidosis
Step #1: Acidosis or alkalosis?

pH <7.4 → Acidosis.

Step #2: Respiratory or metabolic?

The CO2 is high. CO2 is an acid. High acid causes acidosis. CO2 is causing the
problem → Respiratory.

Step #3: Compensation?

Since CO2 is causing the problem, look to HCO3 and see if it is trying to help.
The HCO3 is normal, it is not helping, so this is uncompensated.
Question 3
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.37

b. CO2: 80

c. HCO3: 42
 What do you think the
answer is?

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poll while presenting.
Answer: Fully Compensated Respiratory Acidosis
Step #1: Acidosis or alkalosis?

pH <7.4 → Acidosis.

Step #2: Respiratory or metabolic?

The CO2 is high. CO2 is an acid. High acid causes acidosis. CO2 is causing the problem →
Respiratory.

Step #3: Compensation?

Since CO2 is causing the problem, look to HCO3 and see if it is trying to help. The HCO3 is
high. HCO3 is a base. Lots of base raises our pH. This is helping the problem - so the gas is
compensated. Partially or fully? Look at the pH! It is within the normal range, so the HCO3
has fully fixed the problem. This is a fully compensated blood gas.
Question 4
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.58

b. CO2: 48

c. HCO3: 38
 What do you think the
answer is?

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poll while presenting.
Answer: Partially Compensated Metabolic Alkalosis
Step #1: Acidosis or alkalosis?

pH >7.4 → Alkalosis.

Step #2: Respiratory or metabolic?

The CO2 is high. CO2 is an acid. High acid causes acidosis. The HCO3 is high. HCO3 is a base. A high
base causes alkalosis. We have an alkalosis, so the HCO3 is causing the problem. When HCO3 is
the problem, it is metabolic.

Step #3: Compensation?

Since HCO3 is causing the problem, look to CO2 and see if it is trying to help. The CO2 is high. CO2
is an acid. High acid lowers the pH, and the current pH is too high. This is helping the problem - so
the gas is compensated. Partially or fully? Look at the pH! It is NOT within the normal range, so the
CO2 has only partially fixed the problem. This is a partially compensated blood gas.
Question 5
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.43

b. CO2: 51

c. HCO3: 42
 What do you think the
answer is?

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poll while presenting.
Answer: Fully Compensated Metabolic Alkalosis
Step #1: Acidosis or alkalosis?

pH >7.4 → Alkalosis.

Step #2: Respiratory or metabolic?

The CO2 is high. CO2 is an acid. High acid causes acidosis. The HCO3 is high. HCO3 is a base. A high
base causes alkalosis. We have an alkalosis, so the HCO3 is causing the problem. When HCO3 is
the problem, it is metabolic.

Step #3: Compensation.

Since HCO3 is causing the problem, look to CO2 and see if it is trying to help. The CO2 is high. CO2
is an acid. High acid lowers the pH, and the current pH is too high. This is helping the problem - so
the gas is compensated. Partially or fully? Look at the pH. It is within the normal range, so the CO2
has fully fixed the problem. This is a fully compensated blood gas
Question 6
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.62

b. CO2: 14

c. HCO3: 18
 What do you think the
answer is?

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poll while presenting.
Answer: Partially compensated Respiratory Alkalosis
Step #1: Acidosis or alkalosis?

pH >7.4 → Alkalosis.

Step #2: Respiratory or metabolic?

The CO2 is low. CO2 is an acid. Low acid causes alkalosis. The HCO3 is low. HCO3 is a base. Low
base causes acidosis. The CO2 is causing the problem → Respiratory.

Step #3: Compensation?

Since CO2 is causing the problem, look to HCO3 and see if it is trying to help. The HCO3 is low. Low
HCO3 lowers the pH, and the current pH is too high. This is helping the problem - so the gas is
compensated. Partially or fully? Look at the pH! It is NOT within the normal range, so the HCO3 has
only partially fixed the problem. This is a partially compensated blood gas.
Question 7
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.32

b. CO2: 30

c. HCO3: 20
 What do you think the
answer is?

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poll while presenting.
Answer: Partially Compensated Metabolic Acidosis
Step #1: Acidosis or alkalosis?

pH <7.4 → Acidosis.

Step #2: Respiratory or metabolic?

The CO2 is low. CO2 is an acid. Low CO2 causes alkalosis. The HCO3 is low. HCO3 is a base. A low
base causes acidosis. We have an acidotic condition, so the lack of HCO3 is causing the problem.
When HCO3 is the problem, it is metabolic.

Step #3: Compensation.

Since HCO3 is causing the problem, look to CO2 and see if it is trying to help. The CO2 is low. CO2 is
an acid. Low acid raises the pH, and the current pH is too low. This is helping the problem - so the
gas is compensated. Partially or fully? Look at the pH. It is NOT within the normal range, so the
CO2 has only partially fixed the problem. This is a partially compensated blood gas.
Question 8
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.42

b. CO2: 27

c. HCO3: 18
 What do you think the
answer is?

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poll while presenting.
Answer: Fully Compensated Respiratory Alkalosis
Step #1: Acidosis or alkalosis?

pH >7.4 → Alkalosis.

Step #2: Respiratory or metabolic?

The CO2 is low. CO2 is an acid. Low acid (or lack of acid) can cause alkalosis. The HCO3 is low.
HCO3 is a base. Low base (or lack of base) causes acidosis. The CO2 is causing the problem →
Respiratory.

Step #3: Compensation.

Since CO2 is causing the problem, look to HCO3 and see if it is trying to help. The HCO3 is low. Low
HCO3 lowers the pH. The pH is normal now, but it is >7.4, so we know it was too high before
compensation occurred. The HCO3 is helping the problem - so the gas is compensated. Partially or
fully? Look at the pH! It is within the normal range, so the HCO3 has fully fixed the problem. This is
a fully compensated blood gas.
Question 9
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.37

b. CO2: 32

c. HCO3: 12
Answer: Fully Compensated Metabolic Acidosis
Step #1: Acidosis or alkalosis?

pH <7.4 → Acidosis.

Step #2: Respiratory or metabolic?

The CO2 is low. CO2 is an acid. Low acid causes alkalosis. The HCO3 is low. HCO3 is a base. A low base
causes acidosis. We have an acidosis, so the HCO3 is causing the problem. When HCO3 is the problem, it is
metabolic.

Step #3: Compensation?

Since HCO3 is causing the problem, look to CO2 and see if it is trying to help. The CO2 is low. CO2 is an
acid. Low acid raises the pH. The pH is normal now, but it is <7.4 so we know it was an acidosis before
compensation occurred. The CO2 is helping the problem - so the gas is compensated. Partially or fully?
Look at the pH. It is within the normal range, so the CO2 has fully fixed the problem. This is a fully
compensated blood gas.
Question 10
A client presents with the following ABG results. What is the correct
interpretation?

a. pH: 7.20

b. CO2: 70

c. HCO3: 22
Answer: Uncompensated Respiratory Acidosis
Step #1: Acidosis or alkalosis?

pH <7.4 → Acidosis

Step #2: Respiratory or metabolic?

The CO2 is high. CO2 is an acid. High acid causes acidosis. CO2 is causing the
problem → Respiratory.

Step #3: Compensation?

Since CO2 is causing the problem, look to HCO3 and see if it is trying to help.
The HCO3 is normal…not helping, so this is uncompensated.
Question 11
The nurse is caring for a client with the following ABG result - pH: 7.31 CO2: 32 HCO3: 19.
Which of the following conditions are possible causes for the client’s acid-base imbalance?
Select all that apply.

a. 5-day history of severe diarrhea

b. Hyperemesis gravidarum

c. End-stage renal disease

d. Diabetic Ketoacidosis

e. Chronic Obstructive Pulmonary Disease

f. Hyperglycemic Hyperosmolar Non-ketotic Syndrome

Answer: A, C, and D - Metabolic Acidosis
A is correct. Diarrheal stools are high in bicarbonate. The loss of this bicarbonate, which is a base, from the stools results in metabolic acidosis.

C is correct. End-stage renal disease causes metabolic acidosis due to the inability of the kidneys to produce sufficient bicarbonate. Because bicarb
is a base, and the kidneys cannot make enough of it, acidosis occurs.

D is correct. Diabetic Ketoacidosis can cause metabolic acidosis. This occurs when a client with Type I DM has so little insulin, that the cells have
no glucose for energy and resort to breaking down fat for energy. A byproduct of this fat breakdown is ketones, which are acids, and cause
acidosis.

B is incorrect. Hyperemesis gravidarum is a pregnancy complication resulting in excessive nausea and vomiting. Vomiting causes the client to lose
gastric secretions, which contain large amounts of hydrochloric acid. The loss of this acid causes alkalosis.

E is incorrect. Chronic Obstructive Pulmonary Disease (COPD) can cause acidosis, but it is due to a respiratory cause, not metabolic. In COPD,
clients retain carbon dioxide due to obstructive disease. Because carbon dioxide is an acid, the retention of CO2 causes acidosis. Because the cause
of the acidosis is CO2, it is classified as respiratory acidosis. This client has metabolic acidosis, where the low pH is due to low HCO3 levels, not
high CO2 levels.

F is incorrect. Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS) is a complication of Type II DM. This client is not expected to have an
acid-base imbalance. They have very high blood glucose levels, resulting in symptoms such as dry mouth, polydipsia, polyuria, and tachycardia, but
their body does not resort to breaking down fat for energy. They, therefore, do not produce ketones and do not become acidotic.
Question 12
The nurse is caring for a client recovering from a clonazepam overdose. Which of
the following ABG results would be expected?

A. pH 7.4, CO2 40, HCO3 28

B. pH 7.42, CO2 52, HCO3 42

C. pH 7.56, CO2 22, HCO3 22

D. pH 7.25, CO2 74, HCO3 26

Answer: D - Respiratory Acidosis
D is correct. This is an uncompensated respiratory acidosis. Clonazepam is a benzodiazepine which depresses the central nervous
system. It therefore lowers the respiratory rate and can cause respiratory depression. When the client's respiratory rate decreases too
much, their body retains CO2 (which as an acid, lowers the pH and causes acidosis). The elevated CO2 level and subsequently low
pH is what the nurse would expect after a clonazepam overdose.

A is incorrect. This is a normal ABG, which would not be expected in a client who has experienced a clonazepam overdose.

B is incorrect. This is a fully compensated metabolic alkalosis. An example of a client that the nurse would expect this ABG is a client
who has taken too many over-the-counter antacids, such as Alka-Seltzer. This client has ingested too much sodium bicarbonate
(hence their high HCO3 level), which caused their pH to go up. The body compensating by retaining CO2 (hence the high CO2 level),
and brought he pH back down into normal range. A metabolic alkalosis is not the ABG the nurse would expect for a client who has
experienced a clonazepam overdose.

C is incorrect. This ABG shows an uncompensated respiratory alkalosis. The nurse would expect a client experiencing a panic attack
to have his ABG result. In a panic attack, the client is hyperventilating and losing CO2. The loss of CO2 (an acid), causes the pH to
increase, hence the alkalosis. This ABG is uncompensated, because the HCO3 remains normal and is not helping to fix the abnormal
pH. The nurse would not expect that the client who has experienced a clonazepam overdose would present with respiratory
alkalosis.
Question 13
The nurse is taking the health history of an 87-year-old client and asks about
current medications. The client lists lisinopril, digoxin, and calcium carbonate
Which of the following acid-base imbalances is this client at the highest risk of?

A. Metabolic alkalosis

B. Metabolic acidosis

C. Respiratory acidosis

D. Respiratory alkalosis
Answer: A
A is correct. The client using over-the-counter antacids, such as calcium carbonate, is at risk of
developing metabolic alkalosis. This is due to the high amount of sodium bicarbonate present in this
medication. If the client takes too much of it, their HCO3 level can increase, causing a metabolic alkalosis.

B is incorrect. Clients at risk for metabolic acidosis include those experiencing diarrhea, renal disease,
and diabetic ketoacidosis. These clients are losing HCO3 causing their pH to become acidotic.

C is incorrect. Clients at risk for respiratory acidosis include those with chronic obstructive pulmonary
disorder, those experiencing respiratory depression after an overdose, or any client otherwise
hypoventilating. These clients are retaining CO2 causing their pH to become acidotic.

D is incorrect. Clients at risk for respiratory alkalosis include those who are hyperventilating, such as
when they are experiencing a panic attack. These clients are losing CO2 causing their pH to become
alkalotic.
Question 14
The nurse is working in a psychiatric facility caring for a client experiencing an acute panic attack.
Upon assessing the client, they tell the nurse that they are dizzy, lightheaded, and feel they might
pass out. Which of the following lab values does the nurse expect to note?

A. CO2- 20

B. pH - 7.8

C. HCO3 - 46

D. pH - 7.44

E. CO2 - 35

F. HCO3 - 28
Answer: A, B, and F - Respiratory Alkalosis
A is correct. A low CO2 would be expected in the client having an acute panic attack as their body exhales large amounts of CO2. This results in a
respiratory alkalosis.

B is correct. The client having an acute panic attack is expected to have a high pH. This is due to the loss of CO2 due to hyperventilation.

F is correct. The client having an acute panic attack would be expected to have a normal HCO3 level. In an acute attack, the kidneys have not yet
had time to begin the process of compensating, therefore the HCO3 remains normal. It takes the kidneys hours to days to begin producing more
bicarbonate to raise the pH and compensate for the acidosis. This would be expected in more gradual processes that cause acidosis over days,
such as prolonged diarrhea.

C is incorrect. A high bicarbonate level would indicate that compensation is occurring as the kidneys produce more base to raise the pH and
correct the acidosis. This is not expected during an acute attack, as they kidneys take hours to days to begin the compensation process.

D is incorrect. The client having an acute panic attack would not have a normal pH of 7.44- their pH will be low due to the loss of CO2.

E is incorrect. The client having an acute panic attack would not have a normal CO2 of 35- their CO2 will be low as they are hyperventilating and
losing CO2.
Question 15 - Metabolic Acidosis
While precepting a new graduate nurse, you are assigned to care for a client in diabetic ketoacidosis
(DKA). The new nurse obtains an ABG and the results are as follows: pH: 7.2 CO2: 11 HCO3: 14. Which
of the following statements by the new nurse demonstrate a need for further teaching regarding the
acid-base status of this client? Select all that apply.

A. “Our client is acidotic because they have lost so much CO2”

B. “Because the bicarbonate is causing this imbalance, this is a metabolic alkalosis”

C. “Since our client has been experiencing Kussmaul respirations, it makes sense that their bicarbonate is
so low”

D. “This arterial blood gas is fully compensated”

E. “This client is experiencing a metabolic acidosis, which is expected in DKA. Other clients that could
have this imbalance are those with vomiting or using diuretics”
Answer: A,B,C,D, and E
A is correct. This client is acidotic, but not because they have lost CO2. The normal range for CO2 is 35-45. CO2 is an acid, and the
loss of it therefore results in an alkalosis, or elevated pH; so this statement requires further teaching to the new nurse.

B is correct. This client is not experiencing a metabolic alkalosis, rather they are experiencing a metabolic acidosis. The normal range
for pH is 7.35-7.45, and this client has a low, or acidotic pH at 7.2. If the new nurse states that a metabolic alkalosis is occurring, they
need further education regarding acid base imbalances.

C is correct. Kussmaul respirations are fast, deep respirations that sometimes occur in Diabetic Ketoacidosis (DKA). They are the
body’s response to a metabolic acidosis. By breathing fast and deep, the body is exhaling and therefore removing carbon dioxide, an
acid, from the body. This should raise the pH and help compensate for the acidosis. While it does make sense that the client is having
Kussmaul respirations with their ABG results, it is not the reason that their HCO3 is low; it is the reason that their CO2 is low.

D is correct. This is a partially compensated arterial blood gas, not fully compensated.

E is correct. This statement indicates that the new graduate nurse correctly understands DKA causes metabolic acidosis, but they
incorrectly state other potential causes. Clients with vomiting or diuretic use are at risk for metabolic alkalosis. Other clients who
could experience a metabolic acidosis include clients with diarrhea or renal disease.
 How confident do you feel
with ABGs?

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 Break Believe in yourself, for your potential is limitless!

Back at….
Rachel is in the chat. We will start Fluid and Electrolytes at 10:20 am CT.
Fluids and
Electrolytes
 Fluids and Electrolytes
Sodium
Chloride
Calcium
Phosphorus
Magnesium
Potassium
Fluids
 How do you feel about fluids
and electrolytes?

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poll while presenting.
Electrolyte Lab Values
● Sodium: 135-145 mEq/L
● Potassium: 3.5 - 5 mEq/L
● Calcium: 9 -10.5 mg/dL
● Magnesium: 1.5 - 2.5 mg/dL
● Chloride: 98 - 106 mEq/L
● Phosphorus: 3 - 4.5 mg/dL
Sodium - Na+
● The most abundant extracellular cation
● Regulates water in the cells of the body
● Water follows sodium
● Sodium is important in:
○ The brain
○ Nerves
○ Muscle cells

Normal sodium: 135 - 145 mEq/L

 Hypernatremia
Two ways it can happen….
Fluid loss… the sodium that’s Gain or retain sodium:
left is concentrated:
● Gain
● Increased insensible water ○ Hypertonic IVF
loss ○ Sodium bicarbonate
○ Hyperventilation ○ Increased sodium intake
○ Excessive sweating ● Retain
○ Fever ○ Corticosteroids
● Diabetes insipidus ○ Cushing’s
○ Hyperaldosteronism
Recognize Cues
Assessment
Neuro Musculoskeletal CV Other

● Restless ● Twitching ● Fever ● Flushed skin

● Agitated ● Cramps ● Hypervolemic ● Decreased UOP
● Lethargic ● Weakness ○ Edema ● Dry mouth
● Drowsy ○ Hypertension
● Stupor ○ Bounding pulses

● Coma ● Hypovolemic
○ Hypotension
○ Weak pulses
Treatment
If due to fluid loss: If due to gaining or retaining
sodium:
Get them some more water!
● Free water administration Stop giving them sodium and
○ Based on the free water deficit water!!
● PO intake if mild
● IV Isotonic fluid administration if severe● Find the causative agent and discontinue
○ NS is “relatively hypotonic” to the ○ 3% administration?
body in hypernatremia. ○ Aldosterone excess?
● Loop diuretics
● Free water administration
Key Point:
Monitor neuro status
Correct imbalance SLOWLY - Risk for cerebral edema
 Hyponatremia
Two ways it can happen….
Water in the body Loose sodium:
increases- dilutes the of
sodium: ● Vomiting
● Diarrhea
● SIADH ● NG suction
● Adrenal insufficiency/Addison’s
disease ● Diuretics
● Polydipsia ● Burns
● Excessive hypotonic IVF
● Low dietary intake of sodium ● Excessive sweating
● CHF
● Kidney failure
● Nephrotic syndrome
● Liver failure
● Water intoxication
Recognize Cues
Assessment
Musculoskeletal
Neuro CV
● Abdominal cramps
● Seizures ● Weakness ● Hypovolemia
● Confusion ● Shallow respirations ○ Weak pulse
○ Tachycardia
● Lethargy ● Decreased deep tendon reflexes
○ Hypotension
● Stupor ● Muscle spasms
○ Dizziness
● Orthostatic hypotension
● Cerebral edema ● Hypervolemia
● Increased ICP GI/GU ○ Bounding pulses
○ Hypertension
● Loss of appetite
● Hyperactive bowel sounds
Take Action
Treatment
If due to water gain: If due to sodium loss:
Bring the water down and the Give sodium
sodium up.
● Mild
● Water down ○ 0.9% NS
○ Restrict free water ● Severe
○ Osmotic diuretics ○ 3% NS
● Sodium up
○ Sodium tablets
○ High salt diet
High Salt Diet
● Anything processed!
○ Bacon
○ Butter
○ Canned food
○ Cheese
○ Hot dogs
○ Lunch meat
○ Processed food
○ Table salt
Replacing Sodium
● Replace sodium slowly
● 0.5 mEq/hr
● Changing the sodium level too quickly causes fluid shifts
○ Cerebral edema
○ Increased ICP
NCLEX Question
The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L.
Which of the following signs and symptoms do they suspect are caused by the client's
sodium level? Select all that apply.

A. Lethargy
B. Dry mucous membranes
C. Tachypnea
D. Cyanosis
E. Dry mouth
 What do you think the
answer is?

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poll while presenting.
Answer: A, B, and E
A is correct. Sodium plays a very important role in the brain, and imbalances in the serum sodium level can cause major
neurological changes. The client who is hypernatremic, or has a sodium level greater than 145 mEq/L is at risk for changes
in their level of consciousness ranging from restlessness and agitation to lethargy, stupor, and coma.

B is correct. The client who has a high sodium level, greater than 145 mEq/L will have dry mucous membranes. This is
due to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in
the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes the dry
mouth and mucous membranes.

E is correct. Dry mucous membranes are an expected finding in hypernatremia.

C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very
important role in the brain and nerves as well as water balance. The major symptoms to monitor for will be neurological,
not respiratory.

D is incorrect. Cyanosis, or a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of
the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but
will not result in cyanosis.
 A client comes in with a sodium of
128. What nursing intervention
should you implement?

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Chloride - Cl
● Most abundant extracellular anion
○ Sodium’s sidekick!
● Works with sodium to maintain fluid balance
● Binds with hydrogen ions to form stomach acid - HCl
● Inversely related to bicarbonate
● Directly related to sodium and potassium

Normal chloride: 98-106 mEq/L

Causes Assessment Treatment
Cl
● Fluid loss ● Signs and ● Treat the underlying
○ Dehydration symptoms of cause
○ Vomiting hypernatremia ● Correct the imbalance
○ Sweating
○ Bicarbonate
● Steroids administration
○ Cushing’s disease ○ Discontinue any sodium
○ Excess corticosteroid containing meds
administration ○ No NS for IVFs - consider
● Excess chloride LR instead
administration ● Monitor all electrolytes -
○ NORMAL SALINE! it’s usually not the only
imbalance!
Causes Assessment Treatment
Cl
● Volume overload ● Signs and ● Treat the underlying
○ CHF symptoms of cause
○ Water intoxication hyponatremia ● Correct the imbalance
● Salt losses: ○ Normal Saline - 0.9%
○ Burns NaCL
○ Sweating
● Monitor all electrolytes
○ Vomiting
○ Diarrhea - it’s usually not the
○ Cystic Fibrosis only imbalance!
○ Addison’s Disease
Calcium - Ca
● Stored in the bones, absorbed in the GI system, and excreted by the kidneys
● Plays an important role in bones, teeth, nerves, and muscles
● Important for coagulation
● Is controlled by parathyroid hormone and Vitamin D
● Has an inverse relationship with phosphorus

Normal calcium: 9 - 10.5 mg/dL

 Ca
Hypercalcemia Causes
● Excessive intake of calcium

● Hyperparathyroidism
● Excessive intake of Vitamin D
● Vitamin D toxicity

● Cancer of the bones

● Immobility
 Ca
Recognize
AssessmentCues
Neuromuscular Cardiovascular Gastrointestinal Neuro

● Weakness ● Bradycardia ● Decreased ● Fatigue

● Flaccidity ● Cyanosis peristalsis ● Decreased
● Decreased deep ● Deep vein ● Hypoactive LOC
tendon reflexes thrombosis bowel sounds
● Abdominal pain
● Nausea
● Vomiting
● Constipation
● Kidney stones
Take Action Ca
 Ca
Hypocalcemia Causes
● Renal failure
● Acute pancreatitis
● Malnutrition
● Malabsorption
○ Celiac disease
○ Crohn’s disease
● Alcoholism
● Bulimia
● Vitamin D deficiency
● Hypoparathyroidism
● Hyperphosphatemia
 Ca
Recognize Cues
Assessment
Neuromuscular Gastrointestinal Misc.

● Irritability ● Hyperactive ● Weak bones

● Hallucinations bowel sounds ○ Increased risk of fractures

● Paresthesias ● Cramping ● Weak/brittle nails

● Tetany ● Diarrhea ● Arrhythmias
○ Ventricular Tachycardia
● Seizures
● Muscle spasms
● Chvostek’s sign
● Trousseau’s sign
 Ca
Take Action
● PO calcium supplements
○ Administer with Vitamin D
○ Vitamin D increases absorption of calcium
● IV calcium supplements
● Calcium rich diet
 Calcium works like a

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Phosphorus
● Major role is in cellular metabolism and energy production (ATP)
● Makes up the phospholipid bilayer of cell membranes
● Large component of bones and teeth
● Has an inverse relationship with calcium
○ Calcium’s enemy!

Normal phosphorus: 3.0-4.5 mEq/L

Causes Assessment Treatment P
● Excessive dietary intake of● Symptoms are ● Phosphate binders
phosphorus related to the ○ Given with food

● Tumor lysis syndrome hypocalcemia ● Manage

● Renal failure secondary to hypocalcemia
● Hypoparathyroidism → hyperphosphate
Hypocalcemia → mia.
Hyperphosphatemia
 P
Causes Assessment Treatment
● Malnutrition ● Symptoms are ● Treat the cause
● Alcoholism related to the ● Phosphorus
● TPN hypercalcemia replacement
● Hyperparathyroidism secondary to ○ PO

→ hypercalcemia → hypophosphatemia. ○ IV - given slowly

● Phosphorus rich diet
hypophosphatemia
● Diet low in calcium
Foods High in Phosphorus
NCLEX Question
The nurse is reviewing their clients laboratory findings and notes that one of her clients has a
serum calcium level of 7.2 mg/dL. They know that of each of the following clients, which ones are
most likely to have this result? Select all that apply.

A. The client with breast cancer and bone metastases

B. The client with obesity
C. The client with Vitamin D toxicity
D. The client with hypoparathyroidism
E. The client with chronic renal failure
 What do you think the
answer is?

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 Answer: D and E
D is correct. The client with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 9.0-10.5 mg/dL, so
with this client's level of 7.2 they have too little calcium in the blood. The client who experiences hypoparathyroidism has too little
parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When
there is too little PTH, there are decreased calcium levels, or hypocalcemia.

E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for
hypocalcemia in kidney disease: increased phosphorus and decreased renal production of activated Vitamin D (1,25 Dihydroxy vitamin D).
Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues
and bones, causing hypocalcemia. The kidney is responsible for activating Vitamin D and restoring calcium balance. In the setting of renal
diseases, one loses the capacity to activate vitamin D and calcium level drops. For these reasons, physicians often order phosphate binders
to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/ ESRD.
A is incorrect. The client with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to
bone destruction from osteoclasts and the leak of calcium into blood. In addition, malignancies often cause "paraneoplastic hypercalcemia"
by secreting substances called "PTH-related peptides" that have actions similar to Parathormone ( PTH).

B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in celiac and crohn’s disease clients, can
cause hypocalcemia due to decreased absorption, but obesity would not cause this.

C is incorrect. The client with Vitamin D toxicity would put a client at risk for hypercalcemia, or a serum calcium level greater than 10.5
mg/dL. This is due to the relationship between Vitamin D and calcium; Vitamin D enhances the absorption of calcium. Therefore, Vitamin D
toxicity would lead to increased absorption of calcium and a hypercalcemic state.
Magnesium - Mg
● Stored in the bones and cartilage
● Plays a major role in skeletal muscle contraction
● Important for ATP formation
● Activates vitamins
● Necessary for cellular growth
● Is directly related to calcium
○ Calcium’s friend!

Normal magnesium: 1.5-2.5 mEq/L

 Mg
Hypermagnesemia Causes
● Excessive dietary intake
● Too many magnesium containing medications
● Over-correction of hypomagnesemia
● Renal failure
 Mg
Recognize
AssessmentCues
Neuromuscular Cardiovascular Neuro

● Weakness ● Bradycardia ● Drowsy

● Shallow breathing ● Hypotension ● Lethargy
● Slowed reflexes ● Vasodilation ● Coma
● Decreased deep ○ Flushed
○ Feel warm
tendon reflexes
 Mg
Take Action
● Treat the cause
● Hold any fluids or meds containing magnesium
● Loop diuretics
● Calcium gluconate
● Dialysis
 Mg
Hypomagnesemia Causes
● Alcoholism
● Malnutrition
● Malabsorption
● Hypoparathyroidism
● Hypocalcemia
● Diarrhea
 Mg
Recognize
AssessmentCues
Neuromuscular Neuro Gastrointestinal

● Numbness ● Psychosis ● Nausea

● Tingling ● Confusion ● Vomiting
● Cramping ● Abdominal cramps
CV
● Tetany ● Anorexia
● Seizures ● Torsades de pointes
● Increased deep
tendon reflexes
 Mg
Take Action
● Treat the cause
● Monitor cardiac rhythm
● Administer magnesium
○ PO - Magnesium hydroxide
○ IV - given very slowly
NCLEX Question
The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL.
they know that which of the following could have caused this electrolyte
abnormality? Select all that apply.

A. Renal failure
B. Alcoholism
C. Anorexia
D. Diarrhea
E. Malnutrition
 What do you think the
answer is?

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poll while presenting.
Answer: A
A is correct. The normal magnesium level is 1.5-2.5 mg/dL. This client has a level of 3.2, and is experiencing
hypermagnesemia. Renal failure can cause hypermagnesemia due to the fact that the process that keeps the levels of
magnesium in the body at normal levels does not work properly in people with kidney dysfunction.

B is incorrect. Alcoholism is a risk factor for hypomagnesemia, and this client has hypermagnesemia. Hypomagnesemia is
the most common electrolyte abnormality observed in alcoholic clients. There is a loss of magnesium from tissues and
increased urinary loss, and chronic alcohol abuse depletes the total body supply of magnesium.

C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this client has hypermagnesemia. This is due to
malnutrition and a lack of dietary intake of magnesium.

D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this client has hypermagnesemia. Magnesium is
absorbed in the GI tract, and with diarrhea there is decreased absorption of magnesium leading to hypomagnesemia.

E is incorrect. A client who is malnourished will have had a poor dietary intake of magnesium, leading to
hypomagnesemia.
 We see Torsades de Pointes
on the EKG the nurse should
prepare to

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Potassium - K
● Found mostly inside the cells - most abundant intracellular cation.
● Normal value is for serum level - the potassium in the blood, outside of the cells.
● Responsible for nerve impulse conduction
● Important in muscle contraction - heart muscle and skeletal muscle.
● Important in acid-base balance
○ Acidotic → increased K+

Normal potassium: 3.5 - 5.0 mEq/L

 K
Hyperkalemia Causes
● Too much potassium moved from intracellular to extracellular
○ Burns
○ Tissue damage
○ Diabetic ketoacidosis
● Too much total potassium
○ Renal failure
○ Excessive K+ intake
● Medications
○ ACE inhibitors
○ Potassium-sparing diuretics
Assessment
Recognize Cues K
 K
EKG Changes

● Wide, flat P waves

● Prolonged PR interval
● Widened QRS interval
● Depressed ST segment
● Tall, peaked T waves

Analyze Cues - Can lead to heart block, or V-fib….eventually cardiac arrest!

Take Action K
Interventions depend on severity of hyperkalemia and the symptoms present

● MONITOR CARDIAC RHYTHM ● Drive potassium into cells

○ D5W + regular insulin
● Discontinue any potassium ○ Albuterol
supplements ○ Bicarbonate
○ IV potassium ● Reduce total body potassium
○ PO supplements
○ Kayexalate
● Potassium restricted diet ○ Diuretics
● IV Calcium gluconate or chloride ■ Hydrochlorothiazide
○ Given if EKG changes are present to ■ Furosemide
protect the myocardium ● Dialysis
○ Used when severe hyperkalemia is
not responding to other
interventions
Hypokalemia K
Causes
Drugs Too much water Heavy fluid loss
- Laxatives - Polydipsia - NGT suction
- Diuretics - Excessive IVF - Vomiting
- Corticosteroids administration - Diarrhea
- Wound drainage
- Sweating
Inadequate K intake Cushing’s Syndrome
- NPO - Too much cortisol
- Poor diet - Retention of Na/Water Other
- Anorexia nervosa - Secretion of K - Alkalosis
- Bulimia nervosa - Hyperinsulinism
- Alcoholism ●
Analyze Cues K
● Decreased deep tendon reflexes
● Weakness
● Flaccidity
● Shallow respirations
● Decreased bowel sounds
● Constipation
● Abdominal distention
● Orthostatic hypotension
● Weak, thready pulse
● Cardiac dysrhythmias
 K
EKG Changes

● Slightly peaked P wave

● Slightly prolonged PR interval
● ST depression
● Flat/shallow/inverted T waves
● Prominent u-waves
 K
Take Action
● Prevent arrhythmias
○ Place on cardiac telemetry
○ Hold digoxin
● Prevent further K+ loss
○ Hold furosemide or other potassium
wasting drugs
● Give more potassium
○ IV Potassium supplements
○ Oral potassium supplements
■ Give with food to prevent GI upset
○ Diet rich in potassium
 K
IV potassium supplement administration
● NEVER GIVE IV PUSH
● Give according to instructions; SLOWLY
● Monitor IV site very carefully
○ Can cause phlebitis
○ Extravasation will cause tissue damage
NCLEX Question
The nurse is evaluating their client's lab results and notes that the potassium is 5.5
mEq/L. They review the telemetry monitor, looking for which of the following signs?
Select all that apply.

A. Inverted T waves
B. Widened QRS interval
C. Tall, peaked T waves
D. Prominent U-waves
E. Prolonged PR interval
 What do you think the
answer is?

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Answer: B, C, and E
B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes clients
may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST
segment, and tall, peaked T waves.

C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a very
common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart block,
ventricular fibrillation, or even asystole if left untreated.

E is correct. A prolonged PR interval is one of the EKG changes that occurs with hyperkalemia.

A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia. In
hyperkalemia, there are tall, peaked T waves. Inverted T waves is a sign of hypokalemia.

D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia.
Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia.

NCSBN Client Need:

Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
 A client comes in with a
potassium abnormality. What
should the nurse do first?

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poll while presenting.
Knowledge Check!
1. What electrolyte, when low, can cause a seizure?
Sodium!
2. Which electrolytes have a direct inverse relationship to each other?
Calcium and Phosphorus.
3. What two electrolytes are important for ATP formation?
Magnesium and Phosphate.
4. What electrolyte is the most abundant extracellular anion?
Chloride.
5. What electrolyte abnormality would be expected if torsade-de-pointes
occurs in your client?
Hypomagnesemia.
Answers
1. What electrolyte, when low, can cause a seizure?
Sodium!
2. Which electrolytes have an inverse relationship to each other? Calcium
and Phosphorus.
3. What two electrolytes are important for ATP formation?
Magnesium and Phosphate.
4. What electrolyte is the most abundant anion?
Chloride.
5. What electrolyte abnormality would be expected if torsade-de-pointes
occurs in your client?
Hypomagnesemia.
 IV Fluids
Must know types and
uses!
Osmolarity
“The concentration of a solution expressed as the total number of solute particles per liter”

How much stuff is in this fluid… per liter?

● Water osmolarity
○ 306 mOsm/L
● Urine osmolarity
○ 300-900 mOsm/kg H2O
● Serum osmolarity
○ 285-295 mOsm/kg H2O
Specific Gravity
“The ratio of the density of a substance to the density of a standard, usually water for a liquid”

How much stuff is in this fluid… compared to water?

● Water specific gravity

○ 1
● Urine specific gravity
○ 1.005-1.030
● Serum specific gravity is not normally measured!
Tonicity
“The concentration of a solution as compared to another solution”

How much stuff is in this fluid… compared to something else

vs.
IV Fluid vs. Blood
Isotonic IV Fluids
IV fluid with osmolarity similar to blood. Uses:
Does NOT cause a shift in fluid.
● Increase the intravascular
volume
● Blood loss
● 0.9% Sodium Chloride (Normal
● Surgery
Saline)
● Isotonic dehydration
● Lactated Ringers (LR)
● Fluid loss
● D5W*
● Maintenance fluids
*Technically isotonic, but it becomes hypotonic once in the ● Clients who are NPO
body!!
Hypotonic IV Fluids
IV fluid with osmolarity lower than blood. Uses:
Moves fluid out of blood vessels into cells
and interstitial spaces. ● DKA
● HHNS
● 0.45% Sodium Chloride (½ Normal ● Hypernatremia
Saline)
● 0.33% or 0.2% Sodium Chloride
● 5% Dextrose in Water (D5W)*
● 2.5% Dextrose in Water (D2.5W)
*Technically isotonic, but it becomes hypotonic once in the
body!!
Hypertonic IV Fluids
IV fluid with osmolarity higher than Uses:
blood. Moves fluid out of cells and
interstitial spaces and into blood ● Hyponatremia
vessels. ● Cerebral edema

● 1.5%, 3%, or 5% Sodium Chloride

● D5NS
● D5LR
● D10W
 Which fluid would you most
likely give to a burn client?

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poll while presenting.
 How do you feel about fluid
and electrolytes now?

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poll while presenting.
 End of Part I!

Break
Rachel is in the chat for any more Fluid + Electrolyte questions! We start Part II with the
Cardiovascular System at 11:50 am CT
Back at….
 ABG Interpretation
ABG Interpretation
ABG Practice Questions
Part II: System
by System
Cardiac
Cait Capablanca, RN, BSN
● Ryerson University in Toronto,
Canada
● Worked in the ER and ICU for
the last 5 years
● Critical Care Nursing
certificate
● Loves travelling, and has
worked abroad in Australia!
 Cardiovascular System
Anatomy + Physiology
- Blood flow through the heart
- Cardiac cycle
- Electrical conduction system
- EKGs
- Hemodynamics
Cardiac pharmacology
Cardiovascular Disorders
- Hypertension
- Coronary Artery Disease
- Myocardial Infarction
- Heart Failure
Shock
 How do you feel about the
cardiovascular system?

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poll while presenting.
Complete Blood Count (CBC)
Coagulation Panel
● Activated partial thromboplastin time (aPTT)
○ Tests the intrinsic coagulation cascade
○ Not on anticoagulants: 30 - 40 seconds
○ On Heparin, ‘therapeutic aPTT’ is 1.5-2.5x
normal.
● Prothrombin Time (PT)
○ Tests the extrinsic coagulation cascade
○ 10 - 12 seconds
● International Normalized Ratio (INR)
○ It is calculated from a PT and is used to
monitor how well warfarin is working.
○ Not on anticoagulants: 0.9-1.2
○ Taking warfarin, ‘therapeutic INR’: 2-3
● Other:
○ D-dimer <500 ng/mL
Cardiac Labs
● Troponin
○ Troponins are a group of proteins found in skeletal and cardiac muscle fibers that
regulate muscular contraction
○ Test measures the level of cardiac-specific troponin in the blood to help detect heart
injury
○ Several types of troponin
○ Normal = 0-0.4
● BNP
○ When there is fluid retention, the heart
senses the need to pump harder to move
fluid forward, and releases BNP
○ Test for CHF
○ Normal <100
The Pathway of Blood
Cardiac cycle
Electrical Conduction System
 Which blood vessel brings
deoxygenated blood to the
lungs?

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poll while presenting.
EKGs
Max of 15 students
Measuring the EKG
What the EKG means
P wave:
Atrial depolarization

QRS complex:
Ventricular depolarization

T wave:
Ventricular repolarization
Electrical Conduction System
6 second strip

HR: 9 x 10 = 90
 P-wave: normal
PR Interval: 0.12-0.20
QRS: <0.12
Rate: 60-100
Regularity: Regular

Normal Sinus Rhythm

 P-wave: Normal Causes Interventions
PR Interval: 0.12-0.20 Sleep Fix the cause
QRS: <0.12 Inactivity Atropine
Rate: <60 Very athletic Pacing
Regularity: Regular Drugs
MI

Sinus Bradycardia
 P-wave: Normal Causes Interventions
PR Interval: 0.12-0.20 Caffeine Fix the cause
QRS: <0.12 Exercise
Rate: 100-150 Fever
Regularity: Regular Anxiety
Drugs
Pain
Hypotension
Sinus Tachycardia Volume depletion
 P-wave: Normal Causes Interventions
PR Interval: >0.20 Often an incidental Fix the cause
QRS: <0.12 finding Treatment generally not required
Rate: 60-100 Peds: infection If extreme - pacing
Regularity: Regular Myocarditis
Congenital heart
disease

First degree heart block

First degree heart block v.s. Normal sinus rhythm
 Causes Interventions
P-wave: Not a QRS for every P
Ischemia Fix the cause
PR Interval: longer, longer, longer….drop
Myocarditis Asymptomatic: no treatment
QRS: <0.12
Status post-cardiac required
Rate: 60-100
surgery Symptomatic: Pacing
Regularity: Irregular

Second degree heart block - type 1

(aka Wenckebach or Mobitz I)
 P-wave: Not a QRS for every P Causes Interventions
PR Interval: 0.12-0.20 MI Fix the cause
(when measurable) Ischemia Pacing
QRS: <0.12
Rate: <60
Regularity: Irregular

Second degree heart block - type 2

(aka Mobitz II)
 P-wave: Not matched with QRS, Causes Interventions
regular intervals Damage to the heart Fix the cause
PR Interval: None MI Pacing
QRS: Variable (narrow or wide) Heart valve disease
Rate: <60 Rheumatic fever
Regularity: Regular, uncoordinated Sarcoidosis

Third degree heart block

Pacemakers TYPES:
Transcutaneous
Transvenous
Permanent
EDUCATION
DO:
● Keep a pacemaker identification card in your wallet
● Take a bath and shower 48 hrs post PPM insertion
● Operate household appliances - it’s safe!
● Notify airport security of pacemaker

DON’T:
● Apply pressure over the generator
● Wear tight clothing
● Get lead wires wet (temporary pacemakers)
● Get an MRI
 Atrial Fibrillation
Causes
Heart disease
MI
CHF
Pericarditis

Interventions
Fix the cause
Cardioversion
Antiarrhythmics: Amiodarone
Beta blockers: Metoprolol
Calcium channel blockers:
Diltiazem

Atrial Flutter
 - t h re a tening.
life ,
CAN be ients tolerate
l
Some c do NOT!
some

P-wave: hidden Causes Interventions

PR Interval: immeasurable Caffeine Fix the cause
QRS: <0.12 CHF Cardioversion
Rate: 150 or higher Fatigue Adenosine
Regularity: Regular Hypoxia
Altered pacemaker
in heart

Supraventricular Tachycardia (SVT)

Ventricular Tachycardia (V-Tach) Interventions
Fix the cause

YES pulse:
- Cardioversion
LIFE ING!!!
AT EN
HRE
NO pulse:
Causes (both) T Defibrillate
MI, Ischemia, Hypoxia, Acidosis, CPR
Hypokalemia, Hypotension Epinephrine

Interventions
Fix the cause
Defibrillate
CPR
Epinephrine

Ventricular Fibrillation (V-fib)

 THR LIFE-
EAT
ENI
N G!!!

P-wave: none Causes Interventions

PR Interval: none -Follows VT/VF in cardiac -Fix the cause
QRS: none arrest -CPR
Rate: none -Acidosis -Epinephrine
Regularity: n/a -Hypoxia
-Hypokalemia
-Hypothermia
-Overdose

Asystole
Knowledge Check!
Question 1

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
 What do you think the
answer is?

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Answer: Normal Sinus Rhythm

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
Question 2

a. Normal sinus rhythm

b. Ventricular tachycardia
c. Atrial fibrillation
d. Atrial flutter
 What do you think the
answer is?

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poll while presenting.
Answer: Atrial Fibrillation

a. Normal sinus rhythm

b. Ventricular tachycardia
c. Atrial fibrillation
d. Atrial flutter
Question 3

a. Ventricular tachycardia
b. Atrial tachycardia
c. Atrial fibrillation
d. Ventricular fibrillation
 What do you think the
answer is?

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poll while presenting.
Answer: Ventricular Tachycardia

a. Ventricular tachycardia
b. Atrial tachycardia
c. Atrial fibrillation
d. Ventricular fibrillation
Question 4

a. Supraventricular tachycardia
b. Ventricular tachycardia
c. Atrial tachycardia
d. Sinus tachycardia
 What do you think the
answer is?

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poll while presenting.
Answer: Supraventricular Tachycardia

a. Supraventricular tachycardia
b. Ventricular tachycardia
c. Atrial tachycardia
d. Sinus tachycardia
Question 5

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
 What do you think the
answer is?

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poll while presenting.
Answer: Sinus Bradycardia

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
Question 6

a. Ventricular fibrillation
b. Atrial fibrillation
c. Atrial flutter
d. Ventricular tachycardia
 What do you think the
answer is?

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Answer: Ventricular Fibrillation

a. Ventricular fibrillation
b. Atrial fibrillation
c. Atrial flutter
d. Ventricular tachycardia
Question 7

a. Atrial flutter
b. Ventricular flutter
c. Atrial fibrillation
d. Ventricular fibrillation
 What do you think the
answer is?

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Answer: Atrial Flutter

a. Atrial flutter
b. Ventricular flutter
c. Atrial fibrillation
d. Ventricular fibrillation
Question 8

a. Normal Sinus Rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
 What do you think the
answer is?

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Answer: Sinus Tachycardia

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia
Question 9

a. Pulseless electrical activity

b. Sinus bradycardia
c. Asystole
d. Ventricular fibrillation
 What do you think the
answer is?

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Answer: Asystole

a. Pulseless electrical activity

b. Sinus bradycardia
c. Asystole
d. Ventricular fibrillation
Cardiac Pharmacology
Antihypertensives
● ACE inhibitors
○ Captopril
○ Enalapril
○ Lisinopril
● Angiotensin II Receptor Blockers
○ Losartan
● Calcium Channel Blockers
○ Amlodipine
○ Nifedipine
○ Verapamil
○ Diltiazem
● Direct acting vasodilators
○ Hydralazine
○ Nitroglycerin
Enalapril
Therapeutic class: ACE inhibitor

Indications: Hypertension, CHF

Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels

and decreases aldosterone leading to vasodilation

Nursing Considerations:

● Can cause a dry cough - should be discontinued if it does.

● Monitor BP
● Contraindicated during pregnancy
Losartan
Therapeutic class: Angiotensin II receptor blocker (ARB)

Indications: hypertension, DM neuropathy, CHF

Action: Inhibits vasoconstrictive properties of angiotensin II

Nursing Considerations:

● Monitor BP
● Monitor the client’s fluid levels (I/O’s)
● Monitor renal and liver status
● Contraindicated during pregnancy
Amlodipine
Therapeutic class: Calcium channel blocker
Indications: Hypertension, angina, a-fib/flutter
Action: Blocks transport of calcium into muscle cells inhibiting excitation and
contraction, causes peripheral vasodilation
Nursing Considerations:
● Avoid grapefruit
○ Blocks the enzyme involved in metabolizing calcium channel blockers, causing amlodipine
levels to increase
● Monitor BP - orthostatic hypotension
● Can cause gingival hyperplasia
NCLEX Question
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the
need for additional teaching regarding Nifedipine? Select all that apply.

A. “My gums may swell because of this medication.”

B. “I will avoid getting up too quickly from sitting or lying position.”
C. “I will stop taking calcium supplements since they may negate the effects of
Nifedipine.”
D. “It is highly likely that I will get constipated from this drug”
E. “If I get cough and tongue swelling, I will hold Nifedipine”
 What do you think the
answer is?

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Test Taking Tool
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the
need for additional teaching regarding Nifedipine? Select all that apply.

A. “My gums may swell because of this medication.”

B. “I will avoid getting up too quickly from sitting or lying position.”
C. “I will stop taking calcium supplements since they may negate the effects of
Nifedipine.”
D. “It is highly likely that I will get constipated from this drug”
E. “If I get cough and tongue swelling, I will hold Nifedipine”
Answer: C, D, and E
C is correct. The client should not stop taking their calcium supplements. There is no evidence to say oral calcium
supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore,
this does not reflect correct understanding by the client and needs additional teaching.

D is correct. There is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the
client is highly likely to get constipated from Nifedipine. Therefore, this statement does not reflect correct understanding
by the client and needs additional teaching.

E is correct. The client should not hold Nifedipine if they get cough and tongue swelling. Cough and tongue swelling
(Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI),
which may lead to this side effect, so the nurse will need to explain this to the client.

A is incorrect. Gum/ gingival hyperplasia is a common side effect with extended-standing use of Nifedipine.

B is incorrect. The client should avoid getting up too quickly from sitting or lying position. Because of peripheral
vasodilation, Nifedipine causes postural or orthostatic hypotension. So, the client should be aware of getting up slowly
from the lying/ sitting position so they do not become dizzy.
Beta Blockers
● Propranolol
● Atenolol
● Metoprolol
● Esmolol
● Sotalol
Propranolol
Therapeutic class: Beta-blocker; Antiarrhythmic

Indications: hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol

withdrawal, anxiety

Action: Blocks beta 1 and 2 adrenergic receptors slowing the heart rate

Nursing Considerations:

● Do not discontinue abruptly; discontinue beta-blockers slowly

● Can mask the signs of hypoglycemia; important to monitor blood sugars.
● Caution with asthma and COPD; can potentially cause bronchospasm.
Antiarrhythmics
● Amiodarone
● Adenosine
● Atropine
Adenosine
Therapeutic class: Antiarrhythmic
Indication: SVT
Action: Slows conduction through the AV node, interrupts re-entry pathways
through AV node, restoring normal sinus rhythm
Nursing Considerations:
● There will be a period of asystole after administration
● Warn the client - it will feel like someone kicked them in the chest!
● Warn the family - they will flatline on the monitor!
● Rapid push - or it will not work
● Use with extreme caution in asthmatics
Atropine
Therapeutic class: Antiarrhythmic; anticholinergic
Indications: Excessive secretions, sinus bradycardia, heart block
Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation,
and decreases secretions
Nursing Considerations:

● Monitor for urinary retention and constipation

● Avoid in clients with glaucoma
Cardiac glycosides
● Digoxin
Digoxin
Therapeutic class: Cardiac glycoside

Indications: Heart failure, atrial fibrillation, atrial flutter, cardiogenic shock

Action: Increases contractility (how strong the heart pumps), and decreases the
rate (how fast the heart beats). Acts on the cellular sodium-potassium ATPase,
making the heart more efficient!
Toxicity
Monitor for toxicity in any client taking digoxin!
Narrow therapeutic range!! → Therapeutic lab level: .5-2ng/mL

● Early signs/symptoms:
○ Nausea & vomiting
○ Anorexia
○ Vision changes - yellow/green halos
● Late signs/symptoms
○ Bradycardia → arrhythmias
Monitor for these signs and symptoms and report them to the primary health care
provider early!
Risk factors for toxicity
● Clients with hypokalemia (K<3.5)
○ **If your client is on a loop diuretic, and digoxin, they are more likely to become toxic!**
○ Licorice extract acts like aldosterone (Na/water retention & K loss) → hypokalemia → Digoxin
Toxicity. Licorice extract is in black licorice.
● Clients with hypomagnesemia (Mg<1.5)
● Clients with hypercalcemia (Ca>10.5)
● The elderly!
○ These clients have decreased renal and liver function, making it harder for them to clear any
drugs, so digoxin levels can build up and become toxic more quickly!
Important Nursing Consideration
When should you HOLD your digoxin dose??

In general, if the pulse is less than 60, you should hold digoxin. This will be
slightly different in different age groups. Always check your order!

Antidote: digoxin immune fab

NCLEX Question
A nurse is caring for a client receiving digoxin. The client’s most recent serum
digoxin level was 2.5 ng/mL. Which of the following essential nursing actions
should the nurse take? Select all that apply.

A. Withhold the client’s scheduled dose

B. Administer the dose as prescribed
C. Assess the client's urinary output
D. Assess the client's most recent sodium level
E. Assess the client’s heart rate and rhythm
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Answer: A and E
The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which
means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular
arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal
corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than two ng/mL is considered toxic. The
nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart rate and rhythm (Choice
E) as the client is likely to be experiencing bradycardia.

Choice B, C, and D are incorrect. It would be wrong to administer the next dose, as this would exacerbate the
toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority
here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D
echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an
electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.
Critical Care Medications
● Inotropes: increase the contractility of your heart
○ Dopamine
○ Dobutamine
○ Milrinone
● Vasopressors (vasoconstrictors): cause constriction of the blood vessels,
helping to increase the blood pressure
○ Norepinephrine
○ Epinephrine
○ Vasopressin
○ Phenylephrine
Lunch
Break
TIME: 1:50 pm CT
Hemodynamics
● Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle
● Stroke volume
○ Volume of blood pumped out of the ventricles with each contraction
● Cardiac output
○ The amount of blood the heart pumps through the circulatory system in a minute
Cardiac Output
WHY is cardiac output SO important?!

● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ Shortness of breath, crackles, rales (not enough blood flow to the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

CO = SV X HR
 What can cause an increase
in cardiac output?

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Hypertension
Assessment
● Often asymptomatic until severe
● Vision changes
● Headaches
● Dizziness
● Nosebleeds
● SOB
● Angina
Complications
● Stroke
● MI
● Renal Failure
● Heart Failure
● Vision loss
Treatment & Education
● Medications
○ ACE inhibitors
○ Beta Blockers
○ CCB
○ Diuretics
● Diet
○ DASH
○ Low salt
○ Avoid caffeine and alcohol
○ Weight loss
○ Smoking cessation
● Lifestyle
○ Less sitting more walking
Coronary Artery Disease
(CAD)
What is coronary artery disease?
● The most common type of cardiovascular disease.
● Includes two types
○ Chronic stable angina
○ Acute coronary syndrome (aka MI) Complete plaque blockage
leading to lack of adequate
oxygen to the heart.

Minimal plaque build up.

Chronic Stable Angina
● Chronic disease caused by
narrowing of coronary arteries and
plaque build up
● There are periods of decreased
blood flow to the heart muscle
● Decreased blood flow leads to
decreased oxygen and ischemia
● Ischemia causes chest pain
Treatment
● Nitroglycerin
○ Venous and arterial dilation → decreased afterload → increased CO
○ Given sublingual
○ Administer 1 pill q5 minutes for 3 doses
○ Do not swallow
○ Keep in a dark bottle in dry, cool place
○ Expected side effect = headache
Education
● DECREASE THE WORKLOAD OF THE HEART!
○ Rest
○ Do not overeat
○ No caffeine
○ Avoid temperature extremes
○ No smoking
○ Promote weight loss
○ Reduce stress
Myocardial Infarction
(MI)
Assessment
● Chest pain
○ Crushing
○ Radiating to left arm or jaw
○ Between shoulder blades
● Epigastric discomfort/indigestion
● Fatigue
● SOB
● Vomiting
What is a Myocardial Infarction?
Myocardial infarction = acute coronary syndrome = unstable angina

● There is decreased blood flow to the heart, leading to decreased oxygen

● Not only ischemia, but also necrosis
● Goal is to act quickly and limit the damage
Treatment
● Cath lab within 90 minutes for PCI
○ Percutaneous coronary intervention
○ Especially important if it’s a STEMI!

● ON-TIME
○ O: Oxygen
○ N: Nitroglycerin
○ T: Thrombolytics (if appropriate)
○ I: Antiplatelets (e.g., aspirin or other medications)
○ M: Monitoring and Medical care
○ E: EKG to assess heart activity
Education
● Quit smoking
● Diet
○ Low fat
○ Low salt
○ Low cholesterol
● Exercise
○ Avoid isometric exercises
○ Walking is a good choice
NGN Practice Question
The nurse cares for a 56-year-old in the emergency department experiencing
epigastric pain, shortness of breath, and dizziness.

Nurses’ Notes

1900 – A 56-year-old female presents to the emergency department (ED) with reports of epigastric
pain, shortness of breath, and dizziness. The client reports that the symptoms started eight hours
ago and have progressively worsened. The client arrives pale and diaphoretic. The client has a
medical history of type II diabetes mellitus and stated that her blood glucose has been very high. The
blood glucose was taken, and it was 110 mg/dL.
NGN Practice Question
Which five (5) client findings require follow-up by the nurse?

A. Reports of epigastric pain

B. Blood glucose of 110 mg/dL
C. History of diabetes mellitus type II
D. Reports of shortness of breath
E. Progressive worsening of symptoms
F. Reports of dizziness
G. Pale skin and diaphoresis
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NGN Answer: A, D, E, F, G
Which five (5) client findings require follow-up by the nurse?

A. Reports of epigastric pain

B. Blood glucose of 110 mg/dL
C. History of diabetes mellitus type II
D. Reports of shortness of breath
E. Progressive worsening of symptoms
F. Reports of dizziness
G. Pale skin and diaphoresis
Heart Failure
What is Heart Failure?
The inability of the heart muscle to pump enough blood to meet the body's
needs for blood and oxygen.

● Often results as a complication of other diseases

● #1 cause of HF is hypertension
● Other causes:
○ Cardiomyopathy
○ Endocarditis
○ MI
● Two types: Left and Right
Left-sided Heart Failure
Left side of the heart cannot move blood forward to the body.

Blood is backing up in the LUNGS.

Assessment:

● Pulmonary congestion
● Wet lung sounds
● Dyspnea
● Cough
● Blood tinged sputum
● S3
● Orthopnea
Right Heart Failure
Right side of the heart cannot move blood forward to the lungs.

Blood is backing up in the BODY.

Assessment:

● Jugular venous distention

● Dependent edema
● Hepatomegaly
● Splenomegaly
● Ascites
● Weight gain
● Fatigue
● Anorexia
Treatment
● DECREASE THE WORKLOAD OF THE HEART!
● Primary strategy is to decrease afterload:
○ ACE Inhibitors
■ Arterial dilation→ decreased afterload → Increased stroke volume
○ ARBS
■ Decrease BP → decreased afterload → Increased CO
● Increase contractility
○ Digoxin
● Diuresis
○ Client needs help reducing excess fluid
Education
● Take diuretic medications in the AM
● Monitor electrolyte levels while on diuretics
● Low sodium diet
○ This helps decrease fluid
● Elevate the HOB
○ Will help with breathing
● Daily weight
○ Same time
○ Same scale
○ Same clothes
● Report rapid weight gain (3 lb in a week or 1-2 lb overnight)
 What findings are consistent
with right sided heart
failure? SATA

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 Aortic Aneurysms
A dilation of the aorta typically caused by
atherosclerosis, HTN, smoking, family history

● Abdominal
○ Most common
○ Abdominal, back pain
○ Gnawing/sharp pain
● Thoracic
Rupture
○ Shortness of breath
○ Hoarseness/struggling with swallow ○ Life threatening
○ Back pain ○ Severe pain
○ Do not palpate a pulsating mass
 Air embolism
An air bubble enters a vein or artery

● Very rare
● Complication of surgical procedure
○ High risk: placement of CVC or arterial
catheter
■ If your client suddenly desaturates
during one of these procedures -
suspect an air embolism!

● Positioning:
○ Durant’s maneuver
■ Left lateral trendelenburg
○ This should prevent an air embolism from lodging in the lungs. Will stay in the right heart.
Shock
What is Shock?
● A state where the vital organs are not receiving adequate oxygenation
● This lack of oxygenation causes organ damage and forces the cells to use
anaerobic metabolism to create energy
○ Produces a by-product called lactate
● Cardiovascular system is composed of:
○ The blood
○ The vasculature
○ The heart
● A disruption in any of these three components can cause a lack of oxygen
delivery to the organs, causing shock
● Whichever component is ‘broken’ determines the type of shock
Hypovolemic Shock
Pathophysiology
● Low blood flow
● There is a loss of the circulating volume
● Not enough blood to enter the heart (preload),
which decreases cardiac output
○ The body will vasoconstrict to compensate
○ Not enough blood gets to the tissues
● Not enough oxygen gets to the tissues
● Anaerobic metabolism
● Shock
Hypovolemic Shock
Causes
● Hemorrhage
● Traumatic injury
● Dehydration
○ Vomiting
○ Diarrhea
● Burns
Treatment
● Fix the cause
○ Stop vomiting/diarrhea
○ Stop bleeding
■ Repair in OR
● Replace volume
○ Isotonic IVF
■ NS
■ LR
○ Blood products
● Support perfusion
○ Vasopressors
Blood Administration
● Blood is administered as a medication… so follow the
same “rights”!
● Checked by 2 RNs to ensure compatibility and
correct order
○ Client should have an active Type & Screen to determine
compatibility
● Blood should be administered with special blood
tubing that has a filter with a larger gauge IV
○ Normal saline is the approved compatible IV fluid to infuse
with/after blood
● Ensure vital signs are taken before, during, and after
infusion per hospital policy
○ Baseline vitals are crucial to determine if your client is having a
reaction!!
● Closely monitor client for the first 30 minutes, which
is the most likely time a reaction could occur
Cardiogenic Shock
Pathophysiology
● The heart fails to pump sufficient blood out to the organs
● “Pump failure”
● Something is stopping the heart itself from getting blood out to the body
● Not enough blood gets to the tissues
● Not enough oxygen gets to the tissues
● Anaerobic metabolism
● Shock
Causes
● MI
● Heart failure
● Myocarditis
● Endocarditis
● Cardiomyopathy
● Drug toxicity
OBSTRUCTIVE Cardiogenic Shock
● There is a physical OBSTRUCTION which causes the heart to fail to pump
sufficient blood out to the organs
● Examples:
○ Cardiac tamponade
○ Pulmonary embolism
Cardiac Tamponade
Too much fluid builds up in the
pericardial space

● Leads to increased pressure

in the heart
● Symptoms
○ Muffled heart sounds
○ Jugular vein distention
○ Hypotension
○ Pericardial rub
● Treatment
○ Pericardiocentesis
Assessment
● Decreased perfusion
○ Hypotension
○ Weak pulses
○ Cool, pale, clammy
○ Decreased UOP
○ Decreased LOC
● Volume overload
○ JVD
○ Crackles
○ SOB
○ Muffled heart sounds
○ S3
Treatment
● TREAT THE CAUSE
○ MI
■ PCI
■ CABG
○ PE
■ Thrombolytics
○ Cardiac tamponade
■ Pericardiocentesis
● Improve contractility
○ Dopamine
○ Dobutamine
● Decrease afterload
○ Diuretics
○ Dobutamine
Distributive Shock
Pathophysiology
● Something causes an immune or autonomic response in the body
● This alters vascular tone
● The result is massive peripheral vasodilation
● With so much vasodilation, the blood pressure is inadequate to provide
blood flow to the vital organs.
● Not enough blood gets to the tissues
● Not enough oxygen gets to the tissues
● Anaerobic metabolism
● Shock
●
Assessment
● Decreased oxygen
● Hypotension
● Tachycardia
● Tachypnea
● Warm, flushed skin
● Decreased LOC
Intravenous
access
Central Venous Catheter (CVC)
● IJ
● PICC
● Hickmann
● Broviac
● TT
 How confident do you feel
with the cardiovascular
system?

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Cait Capablanca, RN, BSN
● Ryerson University in Toronto,
Canada
● Worked in the ER and ICU for
the last 5 years
● Critical Care Nursing
certificate
1
● Loves travelling, and has
worked abroad in Australia!
 Break Back at….
Morgan is in the chat for any Cardiac questions! We start Respiratory at 3:20 pm CT.
Lexie Garber, RN, BSN, CEN
• During my career, I have spent
time as a med-surg RN,
Hospice RN, PACU RN and
Emergency Department RN
• Certified Emergency Nurse
(CEN)
• Travel nurse/Crisis nurse
experience
• ACLS/PALS Instructor
• Precepts new nursing
graduates
• Passion for writing
Respiratory
 Respiratory System
Anatomy + Physiology
• Gas exchange
• Breath sounds

Meet our client!

Respiratory Disorders through case study
• COPD
• Asthma
• Pneumonia
• ARDS
ut e s
• PE

m in
70
• Pneumothorax
 How do you feel about the
respiratory system?

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Respiratory System Anatomy
Terminology
● Gas Exchange:
○ The delivery of oxygen from the lungs to the bloodstream
and the elimination of carbon dioxide from the
bloodstream to the lungs. Occurs in the alveoli through
passive diffusion.
● Ventilation
○ Air movement in and out of the lungs
● Oxygenation
○ Oxygen in the bloodstream
● Perfusion
○ Oxygen in the tissues
Work of Breathing
• How easy is it for the client to take a deep breath?
• Retractions
⚬ Note location and severity
⚬ Location
￭ Subcostal
￭ Intracostal
￭ Supraclavicular
￭ Tracheal
• Nasal flaring
• Head bobbing
• Grunting
Let’s meet our client!
 AGE 14 years old

RA
Asthma
What is Asthma?
• A respiratory condition marked by spasms in the bronchi of the lungs, causing
difficulty breathing
• Chronic inflammation of bronchi and bronchioles
• Excess mucus
• Result of an allergic reaction or hypersensitivity
 Pathophysiology
Airway is abnormally reactive - heightened sensitivity

Trigger causes a response

Inflammation and excess mucus production occur

Bronchospasm decreases the airway diameter

Airflow becomes obstructed

After many asthma reactions, airway remodeling occurs

which causes scarring and changes to lung tissue.
Triggers
A - Allergens
S - Sport / Smoking
T - Temperature change
H - Hazards
M - Microbes
A - Anxiety
Assessment
• Shortness of breath
• Unable to speak
⚬ Evaluate how many words they can say before taking a breath
• Cough
• Increased work of breathing
⚬ Retractions
⚬ Tracheal tug
⚬ Head bobbing
• Wheeze
• Prolonged expiration
• Can’t hear any breath sounds? Complete obstruction!
Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist

Indications: Asthma, COPD

Action: Binds to beta-2 adrenergic receptors in the airway leading to relaxation of

the smooth muscles in the airways

Nursing Considerations:
• Be very cautious when using in clients with heart disease, diabetes,
glaucoma, or seizures
• Causes tachycardia
Terbutaline
Therapeutic class: Selective beta 2 adrenergic agonist

Indications: Rescue/Relief and maintenance drug for wheezing, SOB, and coughing caused by
asthma

Action: Binds to beta 2 adrenergic receptors in the respiratory system to cause bronchodilation by
inhibiting the release of hypersensitivity reaction products from mast cells

Nursing Considerations:
⚬ Side effects: jitteriness, dizziness, drowsiness, sleep disturbances, weakness, headache, nausea,
vomiting, tachycardia, hypertension, hyperglycemia, CNS overstimulation
⚬ Assess HR, BP, EKG, blood glucose
⚬ Can be given orally, SC, or by inhaler. 4-6 hour duration. More side effects with oral
administration because it requires higher dosage
⚬ Teach proper inhaler use
Inhalers
• Hold with mouthpiece down. DO NOT hold upside down

• Shake inhaler

• Seal lips tightly around mouthpiece

• Inhale through the mouth slowly

• Press down on inhaler once

⚬ One breath in = one puff of medication

• Continue inhaling while medication is dispensed

(will likely feel cold) - breathe slowly and as
deeply as possible
 AGE 14 years old

5’ 2’’ 112 lbs RA

Treatment - Acute Exacerbation
Airway, breathing, circulation!!

• Airway
⚬ Intubate?
⚬ Adrenergic agonists
• Open up airway
• Albuterol
• Breathing
⚬ Oxygen administration
⚬ Theophylline - Bronchodilator
⚬ Dexamethasone - Steroid - reduce inflammation
• Circulation
⚬ IV fluids
Non-Invasive Ventilation
Complication - Status Asthmaticus
• Asthma attack that is refractory to
treatment
• Leads to severe respiratory failure
• Can progress to death if untreated
We put James on HFNC, started continuous
albuterol, and administered
dexamethasone. Now his asthma attack is
under control. Great job!

Time to talk about long term treatment so

this doesn’t happen again….
Treatment - Long-Term Control
• Inhaled Corticosteroids
Inhaled • Budesonide & fluticasone
⚬ Budesonide & Fluticasone
Corticosteroids • Take daily
⚬ Take daily
• Leukotriene modifiers
• Montelukast sodium
⚬ Montelukast
Leukotriene sodium
modifiers
⚬ • Blocks
Blocks leukotrienes from leukotrienes
over responding from over responding to triggers
to triggers
• Theophylline • Bronchodilator
⚬ Bronchodilator
Theophylline • Helps keep bronchioles open and prevent wheezing, but
⚬ Helps keep bronchioles open and prevent wheezing, but must be used regularly
must be used regularly
• Allergen control
• Clean environment
⚬ Clean environment
Allergen Control • Minimize dust, pet dander, and mold
⚬ Minimize dust, pet dander, and mold
⚬ No secondhand smoke • No secondhand smoke
Steroids
• Betamethasone

• Dexamethasone

• Cortisone

• Methylprednisolone
Methylprednisolone
Therapeutic class: Corticosteroids

Indications: Inflammation, allergy, autoimmune disorders

Action: Suppress inflammation and normal immune response

Nursing Considerations:
• Monitor for too much steroids
⚬ Cushing’s symptoms - buffalo hump
• Side effects
⚬ Immunosuppression
⚬ Hyperglycemia
⚬ Osteoporosis
⚬ Delayed wound healing
Antihistamines

Type Action Example

Histamine-1 Block H1 receptors in CNS

• Diphenhydramine
blocker - stops allergies

Histamine-2 • Famotidine
Block production of stomach acid
blocker • Ranitidine
Diphenhydramine
Therapeutic class: Antihistamine

Indications: Allergy, anaphylaxis, sedation

Action: Antagonizes effects of histamine, CNS depression

Nursing Considerations:
• Monitor for drowsiness
• Anticholinergic effects
NGN Practice Question
The 12-year-old child with a history of asthma is brought to urgent care.

Nurses’ Notes

1700 – 12-year-old male arrives with his parents after playing outside with
friends and suddenly developing shortness of breath. The client’s mother
believes he is having an asthma attack. He has a medical history of asthma,
insulin dependent diabetes mellitus, and is current on all immunizations. No
known allergies.
 NGN Practice Question
Vital Signs Assessment

Oral Temperature 99 ᵒ F Client is alert and fully oriented. Anxious and unable to
(37.2ᵒ C) respond in full sentences. Appears in significant distress.
Pulse 114/minute Peripheral pulses were palpable. Skin was cool and dry to
Respirations 26/minute touch. Respirations were labored with audible wheezes and
Blood pressure 107/76 expiratory stridor. Tachypnea and use of accessory muscles.
mm Hg Frequent, non-productive cough. Active bowel sounds in all
Oxygen saturation 89% quadrants. Client reported no pain.
NGN Practice Question
The nurse reviews the assessment information and identifies that
which two (2) pieces of assessment data require follow-up?
A. The client being anxious
B. Non-productive cough
C. Audible expiratory stridor
D. History of diabetes mellitus
E. Temperature of 99 ᵒ F (37.2ᵒ C)
F. Oxygen saturation of 89%
 What do you think the
answer is?

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NGN Answer- C and F
The nurse reviews the assessment information and identifies which two
(2) pieces of assessment data requires follow-up?

A. The client being anxious

B. Non-productive cough
C. Audible expiratory stridor
D. History of diabetes mellitus
E. Temperature of 99 ᵒ F (37.2ᵒ C)
F. Oxygen saturation of 89%
A cough and the client being anxious are common findings associated with asthma. The
most concerning finding that requires follow-up is the audible stridor and the oxygen
saturation of 89%. Stridor signifies that the upper airways are closing, which indicates that
the asthma attack is advancing. The low oxygen saturation further supports the seriousness
of this asthma attack.
It’s 30 years later. James has caused
airway scarring and remodeling.
Destruction of the alveoli due to
chronic inflammation. A decreased
surface area for gas exchanged.
He has…..
Chronic Obstructive
Pulmonary Disease
(COPD)
What is Chronic Obstructive Pulmonary Disease?
• A group of lung diseases
that block airflow and make
it difficult to breathe
• Includes:
⚬ Emphysema
⚬ Chronic bronchitis
• Damage is not reversible
Assessment
• Barrel chest
• Accessory muscle use
⚬ Retractions
⚬ Nasal flaring
⚬ Tracheal tug

• Congestion
• Lung sounds
⚬ Diminished
⚬ Crackles
⚬ Wheezes

• Acidotic
• Hypercarbic
• Hypoxic
 Nasal cannula
Simple face mask

Treatment
• Be very careful with oxygen administration!
⚬ In the normal client, hypercarbia stimulates the body to breathe
Non-rebreather
⚬ This client has been hypercarbic for an extended period of time
⚬ For them, hypoxia has become the driving factor to stimulate breathing
• Bronchodilators
• Chest physiotherapy
• Increased fluid intake
• Encourage pursed lip breathing to help expire completely
• Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm
 A year later, you move to a
new job at the urgent care and
one night who comes in but
your old friend James! Let’s see
what he came in for...
 AGE 45 years old

RA
The HCP has already ordered a CXR:

Image source: creative comments: view source

 Based on the assessment,
vitals, and chest x-ray what
are your concerns?

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Pneumonia
What is Pneumonia?
• Inflammation of the lung affecting the alveoli

• Alveoli

⚬ Tiny air sacs of the lungs which allow for gas exchange

• Alveoli become filled with pus and liquid

⚬ This blocks exchange from occurring

Classifications
• Viral
⚬ Caused by viruses such as RSV, adenovirus, and influenza
• Bacterial
• Fungal
• Chemical irritation
• Aspiration
⚬ When foreign bodies such as food and secretions enter the lungs
⚬ Causes inflammation and infection leading to pneumonia
Diagnosis
• Chest x-ray
⚬ “Patchy infiltrates”
• Sputum culture
⚬ Will identify a bacterial source

Image source: creative comments: view source

Assessment
• High fever
• Cough
• Tachypnea
• Crackles
• Chest pain
• Work of breathing
⚬ Retractions
⚬ Tracheal tug
⚬ Nasal flaring
⚬ Head bobbing
⚬ Accessory muscle use
⚬ Pursed lip breathing
Treatment • Chest physiotherapy

• Maintain airway • Antipyretics

⚬ Suction • Analgesics
⚬ Monitor SpO₂ • Cough suppressant
• Monitor breathing • Expectorants
⚬ Assess for increased work of breathing
• Antibiotics if bacterial source
⚬ Provide support as needed
⚬ Humidified oxygen
• Isolation (dependent on type)
• Maintain circulation
⚬ Monitor for dehydration
⚬ IVF if unable to tolerate PO
Misc. Respiratory Medications
Montelukast Leukotriene modifier

Guaifenesin Expectorant

Acetylcysteine Mucolytic

Pseudoephedrine, phenylephrine Decongestant

Dextromethorphan, codeine Antitussive

 Well, a few years into your urgent
care career you’ve grown tired of
strep throat and twisted ankles and
decide it’s time to take your skills to
the Emergency Department.
It’s 2:o4 one nightshift when you get the
following report.....
EMS: En route with a 45 yo male in
severe respiratory distress – currently
sats at 87% on 100% FiO2 on a
nonrebreather Nurse: Got It. What’s the story?

EMS: Wife called 911 from the dinner

table. Said he was eating and choked on
some chicken or something – lips Nurse: Ok, does he have any access
started turning blue.
yet?

EMS: We're getting a line now, just

2-3 minutes out.
Nurse: Ok, see you in a few minutes.
Of course, when he arrives, it’s
our old friend James… let’s see
what’s going on.
Acute Respiratory
Distress Syndrome
(ARDS)
What is ARDS?
“An acute condition
characterized by bilateral
pulmonary infiltrates and severe
hypoxemia in the absence of
evidence for cardiogenic
pulmonary edema”

• Fluid collects in alveoli

• Deprives body of oxygen
 What acid-base imbalance
do we see in ARDs?

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Causes
Anything that causes an inflammatory reaction in the lungs!!
• Sepsis
• Trauma
• Burns
• Aspiration pneumonia
• Overdose
• Near drowning

Source: Creative Commons: Transfusion related acute lung injury presenting with acute dyspnoea: a case report. Journal of Medical Case Reports 2008, 2:336.
doi:10.1186/1752-1947-2-336- View original Source here
Assessment
• Chest x-ray
⚬ Diffuse bilateral infiltrates
⚬ “Whited-out”

• Hypoxemia
⚬ Pale
⚬ Cool
⚬ Dusky
⚬ Mottled
⚬ Low SpO2
Treatment
TREAT THE UNDERLYING CONDITION!

Intubation and mechanical ventilation

• High pressures

Prone positioning

Prevent infection
• Ventilator associated pneumonia (“VAP”)

Prevent barotrauma
 James arrives on the
nonrebreather with two 20
gauge IVs. You put him on the
monitor:
 The MD determines James'
airway is in danger. What do
you anticipate?

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Endotracheal
Tube
What is an Endotracheal Tube (ETT)?
Invasive, artificial airway used when the client is unable to protect their own airway

• Plastic tube inserted into the

tracheal through the
• mouth or nose
• Maintains an airway to deliver
oxygen and positive pressure to
the lungs
• “Breathing tube”
Nursing Must Know
• After placement of an ETT, placement should be verified by chest x-ray

• Assess for equal breath sounds and chest rise bilaterally

⚬ The ETT can become displaced into the right main stem bronchus

⚬ Ensure that breath sounds are heard equally bilaterally or the tube may need to be

repositioned
Two attempts to intubate orally have
been unsuccessful. The attending has
STAT overhead paged ENT and is
attempting a third time.
What will be the next step if James
decompensates?
Tracheostomy
What is a Tracheostomy Tube?
• An artificial airway used for long-term needs

• Stoma is made in the neck and the tube is inserted into the trachea

• Breathing occurs through the tracheostomy, not the nose and mouth

Used for:
• Tracheal obstruction

• Slow ventilator weaning

• Tracheal damage

• Neuromuscular damage

• Cannot place ETT tube/client decompensates

Dressing and Ties
Trach Care
Position client into fowler’s or semi-fowler’s Infection prevention is key!
• The natural defenses of the nose
Don PPE and prepare site
and mouth are bypassed
• Perform hand hygiene and don clean gloves • Higher risk for infection
• Remove soiled dressing • Daily trach care in inpatient
• Perform hand hygiene again and don sterile gloves setting
Clean the tracheostomy site • This is a sterile procedure
• Use sterile applicators or gauze dressings moistened with NS
⚬ 1:1 NS and hydrogen peroxide is used with some clients
• Use each applicator/gauze once, then discard
• Dry client’s skin
Apply new sterile dressing

Change tracheostomy ties

• Check tightness - ensure 1 finger can fit underneath
Suctioning and Safety
• Suctioning • Only suction to the pre-measured depth
⚬ Only suction to
⚬ the pre-measured
Suctioning depth
too deep can cause damage or laryngospasm
Suctioning
￭ Suctioning too deep can cause damage or cause laryngospasm
⚬ Don’t suction longer than 10 seconds
￭ Don’t suction longer than 10 seconds
• Some clients may need pre-oxygenation with 100% FiO2
⚬ Some clients may need pre-oxygenation with 100% FiO2
• Safety • Keep two backup tracheostomy tubes at the bedside in case of emergency
⚬ You must keep⚬two
1 ofbackup tracheostomy
the same size tubes at the bedside in case of emergency
￭ 1 of the ⚬same
1 a size
half size smaller
Safety
￭ 1 a half size smaller
• If the trach comes out, first try to insert the backup of the same size
⚬ If the trach comes out, first try to insert the backup of the same size
• If unsuccessful, try to insert the half-size smaller
⚬ If unsuccessful, try to insert the half-size smaller
 The ENT attending arrives at
the last minute and successfully
intubated James. Now that we
have an AIRWAY, how are we
going to help James BREATHE?
Invasive Ventilation
• Endotracheal tube
• Tracheostomy Air Source
Used Air
(CO2) from
• Mechanical ventilator client Airway into lungs
via tube

Air (O2)
to client

Mechanical
ventilator

Client lungs
 Name this vent alarm:
Copious secretions

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 Name this vent alarm:
Tubing disconnected

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 Name this vent alarm:
Client is ‘bucking the vent’

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James is placed on the vent for
his ARDS, let’s remember what
else we can do for him.
Treatment
TREAT THE UNDERLYING CONDITION!

Intubation and mechanical ventilation

• High pressures

Prone positioning

Prevent infection
• Ventilator associated pneumonia (“VAP”)

Prevent barotrauma
 James has to have very high
ventilatory settings to expand his
lungs due to his extensive
pulmonary history. Unfortunately,
these high pressures put him at risk
of a …
Pneumothorax
What is a Pneumothorax?
• Air or gas in the pleural space

⚬ Space between the lung and the chest wall.

⚬ Normally contains a small amount of fluid

⚬ Helps the lungs glide smoothly during breathing.

⚬ When air enters it causes the lung to collapse

• Two types:

⚬ Spontaneous:

￭ No apparent cause, often due to the rupture of small air sacs (alveoli) in the lung,

￭ Commonly seen in those with lung diseases like COPD

⚬ Traumatic:

￭ Caused by chest injuries such as rib fractures, puncture wounds, or medical procedures that accidentally puncture the

lung, like central line insertions or mechanical ventilation

Assessment
• Decreased or absent breath sounds on the affected side

• Asymmetrical chest wall movement on the affected side

• Sudden, sharp, and localized chest pain on the affected side

• Dyspnea

• Rapid, shallow breathing

• Tachypnea

• Cyanosis

• Tension pneumothorax may present with severe respiratory distress, tracheal

deviation away from the affected side, and hemodynamic instability
AGE 47 years old
Treatment and Nursing Interventions
Chest Tube

Semi-Fowler’s position

Oxygen

Deep breathing

Pain management
Chest Tubes
What is a Chest Tube?
• Tube inserted into the pleural space of the
lungs
• Helps to remove air or fluid that has caused
the lung to collapse
• Also placed after cardiac surgery to help
drain blood and fluid from around the heart
Why would our client need a chest tube?
• There is something in the pleural

space….and we need to get it out

⚬ Air

⚬ Fluid

⚬ Blood

• This allows the lung to fully expand

Drainage System Chambers
Nursing Considerations
• Always keep the drainage system below the level of the client's chest
• Ensure the tubing is free of kinks and draining freely
• There should be no dependent loops in the tubing
• Know WHY the client has a chest tube!
• Monitor the drainage
⚬ Color - serous or serosanguinous
⚬ Odor - none
⚬ Consistency - thin-thick
⚬ Amount - no more than 100ml/hr. More? Call the doc!!
￭ Mark hourly
What to do if the chest tube comes out?
• Cover the site with a
sterile dressing
• Tape on 3 sides
⚬ Air can escape this way.
If you tape on 4 sides
you might cause a
tension pneumothorax
• Call the primary
healthcare provider
• STAY WITH THE CLIENT
What to do if the tube
disconnects from the
drainage collection
system?
• Chest tube is still in the client, but
becomes disconnected from the
collection chamber
• Place the end of the chest tube in a
bottle of sterile water
 James has been in the hospital on
bedrest for three weeks now. He has
a DVT and he becomes anxious,
starts picking at the sheets, and
complains of chest pain...
What are you worried about?
Pulmonary Embolism
What is a Pulmonary Embolism?
• Life threatening blood clot in the lungs
• Can be caused by an embolism from a vein entering the lung,
or a clot during surgery
• The clot decreases perfusion causing hypoxemia
• Can lead to right heart failure if untreated
Assessment
• Anxiety
• Dyspnea
• Chest pain
• Hypoxemia
• Rales
• Diaphoresis
• Hemoptysis
Treatment and Nursing Interventions
• Oxygen administration
• Positioning
⚬ High fowler’s
⚬ Promotes maximum lung expansion and assists with breathing
• Anticoagulants
• Thrombolytics
 What position do you use for
a pulmonary embolism?

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 Pulmonary
Air embolism
embolism
• Positioning: • Positioning
⚬ Durant’s maneuver: Left lateral ⚬ High fowler’s
trendelenburg
You sit James up and push the
call bell....
 How confident do you feel
with the respiratory system?

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Lexie Garber, RN, BSN, CEN
• During my career, I have spent
time as a med-surg RN,
Hospice RN, PACU RN and
Emergency Department RN
• Certified Emergency Nurse
(CEN)
• Travel nurse/Crisis nurse
experience
• ACLS/PALS Instructor
• Precepts new nursing
graduates
• Passion for writing
Delegation
NCLEX Question
A nurse working in a busy long-term care facility needs to delegate to the
unlicensed assistive personnel she is working with. Which of the following tasks
would be appropriate to delegate? Select all that apply.

A. Performing an initial assessment

B. Checking vital signs
C. Setting up oxygen
D. Listen to the client’s lung sounds
E. Administering acetaminophen for pain score of 3
 What do you think the
answer is?

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Answer: B and C
B is correct. Checking vital signs is an appropriate task to delegate.

C is correct. Setting up oxygen is part of routine room set up and is an appropriate

task to delegate.

A is incorrect. Performing an initial assessment is not an appropriate task to delegate.

Assessment is out of the scope of practice of unlicensed assistive personnel.

D is incorrect. Listening to the client’s lung sounds requires assessment, which is out
of the scope of practice of unlicensed assistive personnel.

E is incorrect. Administering medications is out of the scope of the unlicensed

assistive personnel
NCLEX Question
The nurse and the LPN are working a busy shift at the pediatric ward. The nurse,
to provide efficiency in the ward, should delegate which task to the LPN?

A. Administration of a medication in syrup form to an infant with a cleft palate

B. Providing discharge instructions to the mother of a child with epiglottitis
C. Changing of a colostomy bag to a toddler with anal atresia
D. Assess a child’s developmental level
 What do you think the
answer is?

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Answer: C
Choice C is correct. The LPN can perform a colostomy change. This is a routine nursing procedure that the LPN can
perform adequately.

An LPN (Licensed practical nurse) scope of practice includes providing ostomy care, monitoring the findings of
Registered Nurse, reinforcing patients education, administration of most medications in stable patients, caring for
ostomy sites/tubes; enteral feeding and checking for feeding tube patency.

An LPN may not perform an initial assessment: Initial assessments are to be performed by a registered nurse (RN).
The first assessment is to be used to determine a patient’s baseline and develop an initial nursing plan of care. Once the
first assessment has been completed, and the nursing plan of attention has been developed, the LPN may assist the RN
in nursing process. The LPN is to communicate any change of a patient’s status to the RN.

Choice A is incorrect. The LPN cannot administer medications in this case of a child with a cleft palate. This is because
a child’s cleft palate poses a risk for aspiration to the infant. This needs the expertise and assessments of the registered
nurse.

Choice B is incorrect. The LPN cannot provide discharge instructions.

Choice D is incorrect. Assessment of a child’s developmental level needs the skills and expertise of the nurse.
NCLEX Question
Due to an absent staff nurse, the postpartum unit is assigned a nurse from the
medical ward as a floater. Which of the following clients should the charge nurse
assign to the float nurse?

A. A 20-hour postpartum client who will be discharged the following morning

B. A 16-hour postpartum client who had eclampsia during delivery
C. A 10-hour postpartum client who has soaked 4 perineal pads in one hour.
D. A 5-hour postpartum client whose fundus is still not at the midline.
 What do you think the
answer is?

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 Answer: B
Choice B is correct. This client can be assigned to the float nurse. The nurse is floating from the medical unit to the postpartum
unit. Eclampsia is a complication of preeclampsia and is characterized by high blood pressure and seizures. This client remains at
risk for a seizure. The goals of management of Eclampsia involve controlling seizures and controlling hypertension. Medical unit
nurses understand and are experienced in taking care of clients having seizure.

Choice A is incorrect. The client is being discharged from the postpartum unit. She needs to be assessed whether she has the
capability to take care of her baby once at home. She also needs to be educated by the nurse about newborn care. A specialized
nurse with postpartum unit-specific experience should be assigned to this client.

Choice C is incorrect. This clients seems to be having primary Postpartum Hemorrhage (PPH). Uterine atony is one of the leading
causes of PPH. Specialized interventions (uterine massage, starting Pitocin drip, etc.) may be needed to control PPH. Therefore, a
dedicated nurse with postpartum unit-specific experience should be assigned to this client.

Choice D is incorrect. Soon after delivery, the uttering fundus (upper portion of the uterus), is midline and at 1 to 2 hours
postpartum, it is palpable halfway between the symphysis pubis and the umbilicus. About 12 hours postpartum, the fundus is at
level of the umbilicus. In this scenario, at 5 hours postpartum, the client’s fundus is not yet at the midline. This means the fundus is
displaced, and the most frequent cause of a displaced fundus is a full bladder. A full bladder may predispose to postpartum
hemorrhage because it interferes with normal involution (contraction) of the uterus. The client should be asked to void. The
medical nurse is usually not specialized in palpating the fundus, and therefore, this client should be assigned to unit-specific
experienced nurse.
From the Board of Nursing….

“The licensed nurse cannot delegate

nursing judgement or any activity that
will involve nursing judgement or critical
decision making”
 What questions do you
have?

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 Day 1-
done!
See you tomorrow morning at 9:00 am!