Pulse (beats/ RR (breaths/ Systolic blood Pulse (beats/ RR (breaths/ Systolic blood

min) min) pressure min) min) pressure

Adult > 18 yrs 60-100 12-20 100-140 Adult > 18 yrs 60-100 12-20 100-140

Adolescent 60-100 12-16 90-110 Adolescent 60-100 12-16 90-110

12-18 yrs 12-18 yrs

Children 70-120 18-30 80-110 Children 70-120 18-30 80-110

5-12 yrs 5-12 yrs

Preschool 80-140 22-34 80-100 Preschool 80-140 22-34 80-100

4-5 yrs 4-5 yrs

Toddler 90-150 24-40 80-100 Toddler 90-150 24-40 80-100

1-3 yrs 1-3 yrs

Infants 100-160 30-60 70-95 Infants 100-160 30-60 70-95

1 month to 1 yr 1 month to 1 yr

Newborn to 1 120-160 40-60 50-70 Newborn to 1 120-160 40-60 50-70

month month
Ventrogluteal landmarks Ventrogluteal landmarks
Note: no dorsogluteal injections!!! Site no longer Note: no dorsogluteal injections!!! Site no longer
Recommended. Preferred infant site: vastus lateralis Recommended. Preferred infant site: vastus lateralis
Subcutaneous shots can be given straight in at a 90 degree angle, or at a 45 Subcutaneous shots can be given straight in at a 90 degree angle, or at a 45
degree angle. Give the shot straight in at a 90 degree angle if 2 inches of skin degree angle. Give the shot straight in at a 90 degree angle if 2 inches of skin
can be grasped between your thumb and first (index) finger. If only 1 inch of can be grasped between your thumb and first (index) finger. If only 1 inch of
skin can be grasped, give the shot at a 45 degree angle. skin can be grasped, give the shot at a 45 degree angle.
Mixing insulins. Ensure the insulins can be mixed! Most facilities don’t Mixing insulins. Ensure the insulins can be mixed! Most facilities don’t
mix anymore mix anymore

1. Air to cloudy (don’t draw up yet!) 1. Air to cloudy (don’t draw up yet!)
2. Air to clear, draw up clear. 2. Air to clear, draw up clear.
3. Draw up cloudy. 3. Draw up cloudy.
4. Inject 4. Inject
Code Blue– cardiopulmonary arrest Code Blue– cardiopulmonary arrest

Code Black– weather related emergency Code Black– weather related emergency

Code pink– infant abduction or pediatric code Code pink– infant abduction or pediatric code

Code red– fire Code red– fire

Code white– disruptive physician Code white– disruptive physician

These codes will vary by hospital. These codes will vary by hospital.

Important phone numbers: Important phone numbers:

Instructor Instructor
Unit: Unit:
Unit: Unit:
Unit: Unit:
Unit: Unit:
Unit: Unit:
Dietary: Dietary:
Linen: Linen:
Transportation: Transportation:
Lab: Lab:
Pharmacy: Pharmacy:
Operator: Operator:

Door codes: Door codes:

Rotation objectives: Rotation objectives:

Skills you may perform: Skills you may perform:

Common diagnoses on this floor: Common diagnoses on this floor:

Common medications on this floor: Common medications on this floor:

A. (Acid) The Respiratory System
CO2 is a volatile acid.
1. If you increase your respiratory rate (hyperventilation) you "blow off" CO2
(acid) therefore decreasing your CO2 (acid)--giving you Alkalosis.
2. If you decrease your respiratory rate (hypoventilation) you retain CO2
(acid) therefore increasing your CO2 (acid)--giving you Acidosis.
B. (Base) The Renal System
The Kidneys rid the body of nonvolatile acids (H+=Hydrogen ions) and
maintain a constant HCO3 (bicarbonate = base).
1. You have Acidosis when you have excess H+ and decreased HCO3 (base)
causing a decrease in pH.
The Kidneys try to adjust for this by excreting H+ and retaining HCO3
(base).
The Respiratory System will try to compensate by increasing ventila-
tion to blow off CO2 (acid) and therefore decrease the Acidosis.
3. You have Alkalosis when H+ decreases and you have excess (or increased)
HCO3 (base).
The Kidneys excrete HCO3 (base) and retain H+ to compensate.
The Respiratory System tries to compensate with hypoventilation to
retain
CO2 (acid) to decrease the Alkalosis.
4. There are other "buffers" involved here--like Carbonic Acid, Ammonia,
and Protein. (Hgb)
C. Compensation
The Respiratory System can effect a change in 15-30 minutes.
The Renal System takes several hours to days to have an effect.
A. (Acid) The Respiratory System
CO2 is a volatile acid.
1. If you increase your respiratory rate (hyperventilation) you "blow off" CO2
(acid) therefore decreasing your CO2 (acid)--giving you Alkalosis.
2. If you decrease your respiratory rate (hypoventilation) you retain CO2
(acid) therefore increasing your CO2 (acid)--giving you Acidosis.
B. (Base) The Renal System
The Kidneys rid the body of nonvolatile acids (H+=Hydrogen ions) and
maintain a constant HCO3 (bicarbonate = base).
1. You have Acidosis when you have excess H+ and decreased HCO3 (base)
causing a decrease in pH.
The Kidneys try to adjust for this by excreting H+ and retaining HCO3
(base).
The Respiratory System will try to compensate by increasing ventila-
tion to blow off CO2 (acid) and therefore decrease the Acidosis.
3. You have Alkalosis when H+ decreases and you have excess (or increased)
HCO3 (base).
The Kidneys excrete HCO3 (base) and retain H+ to compensate.
The Respiratory System tries to compensate with hypoventilation to
retain
CO2 (acid) to decrease the Alkalosis.
4. There are other "buffers" involved here--like Carbonic Acid, Ammonia,
and Protein. (Hgb)
C. Compensation
The Respiratory System can effect a change in 15-30 minutes.
The Renal System takes several hours to days to have an effect.
A. Respiratory Acidosis pH < 7.35 (Normal = 7.35-7.45)
CO2 > 45 (Normal = 35-45)
1. Causes:
--Hypoventilation
a. Depression of the Respiratory Center (sedatives, narcotics,
drug overdose, CVA, cardiac arrest, MI)
b. Respiratory muscle paralysis (spinal cord injury, Guillian-
Barre, paralytics)
c. Chest wall disorders (flail chest, pneumothorax)
d. Disorders of the lung parenchyma (CHF, COPD, pneumonia,
aspiration, ARDS)
e. Alteration in the function of the abdominal system (distention)
2. Signs and Symptoms:
a. CNS depression (decreased LOC)
b. Muscle twitching which can progress to convulsions
c. Dysrhythmias, tachycardia, diaphoresis (related to hypoxia
secondary to hypoventilation)
d. Palpitations
e. Flushed skin
f. Serum electrolyte abnormalities including elevated K+ (K+
leaves the cell to replace the H+ buffers leaving the cell)
3. Treatment:
a. Physically stimulate the pt to improve ventilation
b.Vigorous pulmonary toilet (chest PT, coughing and deep
breathing, inspirometer, respiratory treatments with Bronchodilators)
c. Mechanical Ventilation (to increase the respiratory rate and
tidal volume
A. Respiratory Acidosis pH < 7.35 (Normal = 7.35-7.45)
CO2 > 45 (Normal = 35-45)
1. Causes:
--Hypoventilation
a. Depression of the Respiratory Center (sedatives, narcotics,
drug overdose, CVA, cardiac arrest, MI)
b. Respiratory muscle paralysis (spinal cord injury, Guillian-
Barre, paralytics)
c. Chest wall disorders (flail chest, pneumothorax)
d. Disorders of the lung parenchyma (CHF, COPD, pneumonia,
aspiration, ARDS)
e. Alteration in the function of the abdominal system (distention)
2. Signs and Symptoms:
a. CNS depression (decreased LOC)
b. Muscle twitching which can progress to convulsions
c. Dysrhythmias, tachycardia, diaphoresis (related to hypoxia
secondary to hypoventilation)
d. Palpitations
e. Flushed skin
f. Serum electrolyte abnormalities including elevated K+ (K+
leaves the cell to replace the H+ buffers leaving the cell)
3. Treatment:
a. Physically stimulate the pt to improve ventilation
b.Vigorous pulmonary toilet (chest PT, coughing and deep
breathing, inspirometer, respiratory treatments with Bronchodilators)
c. Mechanical Ventilation (to increase the respiratory rate and
tidal volume
B. Respiratory Alkalosis pH > 7.45 B. Respiratory Alkalosis pH > 7.45
CO2 < 35 CO2 < 35

1. Causes: 1. Causes:

--Alveolar Hyperventilation --Alveolar Hyperventilation

a. Psychogenic (fear, pain, anxiety) a. Psychogenic (fear, pain, anxiety)

b. CNS stimulation (brain injury, ETOH, early salicylate poi-
soning, brain tumor)
c. Hypermetabolic states (fever, thyrotoxicosis)
d. Hypoxia (high altitude, pneumonia, heart failure, pulmonary
embolism)
e. Mechanical overventilation (ventilator rate too fast)
b. CNS stimulation (brain injury, ETOH, early salicylate poi-
soning, brain tumor)
c. Hypermetabolic states (fever, thyrotoxicosis)
d. Hypoxia (high altitude, pneumonia, heart failure, pulmonary
embolism)
e. Mechanical overventilation (ventilator rate too fast)

2. Signs and Symptoms: 2. Signs and Symptoms:

a. Headache a. Headache
b. Vertigo b. Vertigo
c. Paresthesias (numb fingers/toes/circumoral, carpal pedal c. Paresthesias (numb fingers/toes/circumoral, carpal pedal
spasms and tetany) spasms and tetany)
d. Tinnitus (ringing in the ears) d. Tinnitus (ringing in the ears)
e. Electrolyte abnormalities (decreased Ca+, K+) e. Electrolyte abnormalities (decreased Ca+, K+)

3. Treatment: (treat the underlying cause) 3. Treatment: (treat the underlying cause)

a. Sedatives or analgesics a. Sedatives or analgesics

b. Correction of hypoxia (possible diuretics, mechanical ventila-
tion to also decrease respiratory rate and decrease the tidal volume)
(Note: Brain Injury pt. may need hyperventilation)
c. Antipyretics for fever
d. Treat hyperthyroidism
e. Breathe into a paper bag for hyperventilation
b. Correction of hypoxia (possible diuretics, mechanical ventila-
tion to also decrease respiratory rate and decrease the tidal volume)
(Note: Brain Injury pt. may need hyperventilation)
c. Antipyretics for fever
d. Treat hyperthyroidism
e. Breathe into a paper bag for hyperventilation
C. Metabolic Acidosis pH < 7.35
HCO3 < 22 (normal = 22 – 26)
1. Causes:
--Increased H+, excess loss of HCO3
a. Overproduction of organic acids (starvation, ketoacidosis,
increased catabolism)
b. Impaired renal excretion of acid (Renal Failure)
c. Abnormal loss of HCO3 (diarrhea, biliary fistula, Diamox)
d. Ingestion of acid (salicylate overdose, oral anti-freeze)
2. Signs and Sypmtoms:
a. CNS depression (confusion to coma)
b. Cardiac Dysrhythmias (elevated T wave, wide QRS to Ven-
tricular Standstill)
c. Electrolyte abnormalities (elevated K+, Cl-, Ca+)
d. Flushed skin (arteriolar dilitation)
e. Nausea
3. Treatment: (treat the underlying cause)
a. NAHCO3 (Sodium Bicarbonate) based on ABGs only and
with caution
b. IV fluids and Insulin for DKA
c. Dialysis for Renal Failure
d. Antibiotics, increased nutrition for tissue catabolism
e. Increase cardiac output and tissue perfusion for low C.O.
states
f. Rehydrate, monitor I & O
g. Treat Dysrhythmias, support hemodynamic and respiratory
status
C. Metabolic Acidosis pH < 7.35
HCO3 < 22 (normal = 22 – 26)
1. Causes:
--Increased H+, excess loss of HCO3
a. Overproduction of organic acids (starvation, ketoacidosis,
increased catabolism)
b. Impaired renal excretion of acid (Renal Failure)
c. Abnormal loss of HCO3 (diarrhea, biliary fistula, Diamox)
d. Ingestion of acid (salicylate overdose, oral anti-freeze)
2. Signs and Sypmtoms:
a. CNS depression (confusion to coma)
b. Cardiac Dysrhythmias (elevated T wave, wide QRS to Ven-
tricular Standstill)
c. Electrolyte abnormalities (elevated K+, Cl-, Ca+)
d. Flushed skin (arteriolar dilitation)
e. Nausea
3. Treatment: (treat the underlying cause)
a. NAHCO3 (Sodium Bicarbonate) based on ABGs only and
with caution
b. IV fluids and Insulin for DKA
c. Dialysis for Renal Failure
d. Antibiotics, increased nutrition for tissue catabolism
e. Increase cardiac output and tissue perfusion for low C.O.
states
f. Rehydrate, monitor I & O
g. Treat Dysrhythmias, support hemodynamic and respiratory
status
D. Metabolic Alkalosis pH > 7.45
HCO3 > 26
1. Causes:
--Loss of H+ or increased HCO3
a. Large losses of gastric contents (vomiting, NG suction)
b. Loss of K+ (diarreah, vomiting)
c. Ingestion of large amounts of bicarbonate (antacids, resuscitation)
d. Prolonged use of diuretics (distal tubule lose ability to reabsorb Na+
and Cl- therefore Na+, Cl-, K+,
Ammonia are lost in the urine and these bind with H+)
(Note: al-K+-low-sis means K+ value is low when pt is alkalotic)
2. Signs and Symptoms: (similar to the associated disease process)
a. Diaphoresis
b. Nausea and Vomiting
c. Increase neuromuscular excitability (Ca+ binds with protein)
d. Shallow breathing (Respiratory Compensation)
e. EKG changes (increased QT, Sinus Tachycardia)
f. May also see confusion progressing to lethargy to coma
g. Electrolyte abnormality (decreased Ca+, normal or decreased K+, in-
creased Base Excess on the ABG)
3. Treatment: (treat the underlying cause)
a. Replace KCL losses in 0.9% NaCl (rehydrates and increases HCO3
excretion)
b. Diamox (Acetazolamide) (increases HCO3 excretion)
c. Monitor neuro status, re-orient, seizure precautions, monitor I & O
D. Metabolic Alkalosis pH > 7.45
HCO3 > 26
1. Causes:
--Loss of H+ or increased HCO3
a. Large losses of gastric contents (vomiting, NG suction)
b. Loss of K+ (diarreah, vomiting)
c. Ingestion of large amounts of bicarbonate (antacids, resuscitation)
d. Prolonged use of diuretics (distal tubule lose ability to reabsorb Na+
and Cl- therefore Na+, Cl-, K+,
Ammonia are lost in the urine and these bind with H+)
(Note: al-K+-low-sis means K+ value is low when pt is alkalotic)
2. Signs and Symptoms: (similar to the associated disease process)
a. Diaphoresis
b. Nausea and Vomiting
c. Increase neuromuscular excitability (Ca+ binds with protein)
d. Shallow breathing (Respiratory Compensation)
e. EKG changes (increased QT, Sinus Tachycardia)
f. May also see confusion progressing to lethargy to coma
g. Electrolyte abnormality (decreased Ca+, normal or decreased K+, in-
creased Base Excess on the ABG)
3. Treatment: (treat the underlying cause)
a. Replace KCL losses in 0.9% NaCl (rehydrates and increases HCO3
excretion)
b. Diamox (Acetazolamide) (increases HCO3 excretion)
c. Monitor neuro status, re-orient, seizure precautions, monitor I & O
CBC components norms Facility norms significance CBC components norms Facility norms significance

Wbc 5000-10000/mm3 See varying component Wbc 5000-10000/mm3 See varying component
cells. Measure infection. cells. Measure infection.
Also called leukocytes Also called leukocytes

Rbc M: 4.5-6 million/ # of RBC in a volume of Rbc M: 4.5-6 million/ # of RBC in a volume of
blood blood
mL mL
F: 4-5.5 million/mL F: 4-5.5 million/mL
Hct M: 40-50% Ratio of volume of red Hct M: 40-50% Ratio of volume of red
cells to volume of whole cells to volume of whole
F: 35-45% blood F: 35-45% blood

Hgb M: 14-18 g/dL Amount of Hgb M: 14-18 g/dL Amount of

hemoglobin in a volume hemoglobin in a volume
F: 12-16 g/dL of blood F: 12-16 g/dL of blood

MCV 80-95 cubic Average volume of an MCV 80-95 cubic Average volume of an
RBC RBC
micrometers micrometers

MCH 27-31 pg Average amt of Hgb in MCH 27-31 pg Average amt of Hgb in
average RBC average RBC

MCHC 32-36 g/dL Avg concentration of Hgb MCHC 32-36 g/dL Avg concentration of Hgb
in given volume of RBC in given volume of RBC

RDW 11-15% Measures RDW 11-15% Measures

variability of RBC size variability of RBC size
and shape and shape

Neutrophils 2500-8000 /mm3 Most common type of Neutrophils 2500-8000 /mm3 Most common type of
WBC. Part of immune WBC. Part of immune
system. Go to sites of system. Go to sites of
trauma and inflammation trauma and inflammation

Eosinophils 50-500/mm3 Combat parasites, asthma, Eosinophils 50-500/mm3 Combat parasites, asthma,
allergies, part of immune allergies, part of immune
system system

Basophils 25-100/mm3 Inflammation. Contain Basophils 25-100/mm3 Inflammation. Contain

histamine and heparin. histamine and heparin.

Lymphocytes 1000-4000 /mm3 T cells, B cells and NK Lymphocytes 1000-4000 /mm3 T cells, B cells and NK
cells. Immune defense. cells. Immune defense.

Monocytes 100-700/mm3 Immune response. Monocytes 100-700/mm3 Immune response.

Phagocytosis Phagocytosis

platelets 140000-400000/ Number of platelets in a platelets 140000-400000/ Number of platelets in a

given volume of blood given volume of blood
mm3 mm3
Lab value norms Facility norms significance Lab value norms Facility norms significance

ALP 30-100 U/L Liver disease ALP 30-100 U/L Liver disease
Bone disorders Bone disorders

ALT 5-40 U/L Alanine aminotransferase ALT 5-40 U/L Alanine aminotransferase
is released when the liver is released when the liver
is damaged is damaged

Amylase 50-90 U/L Used with lipase test to Amylase 50-90 U/L Used with lipase test to
diagnose pancreatitis diagnose pancreatitis

AST 5-40 U/L Aspartate aminotransferase AST 5-40 U/L Aspartate aminotransferase
found in heart, liver, and found in heart, liver, and
skeletal muscles skeletal muscles

Bilirubin Total 0.1-1.25 mg/dL Varies widely with age of Bilirubin Total 0.1-1.25 mg/dL Varies widely with age of
Direct 0.1-0.3 mg/dL patient, liver function, Direct 0.1-0.3 mg/dL patient, liver function,
Indirect 0.2-1 mg/dL prematurity, trauma, etc Indirect 0.2-1 mg/dL prematurity, trauma, etc

BUN 8-20 mg/dL Blood urea nitrogen. BUN 8-20 mg/dL Blood urea nitrogen.
Evaluates kidney function Evaluates kidney function

chloride 91-110 mEq/L Can help determine cause chloride 91-110 mEq/L Can help determine cause
of electrolyte imbalance. of electrolyte imbalance.
Helps maintain acid base Helps maintain acid base
balance balance

creatinine 0.75-1.5 g/day Evaluates kidney function creatinine 0.75-1.5 g/day Evaluates kidney function

INR 0.9-1.3 no therapy Standardized ratio to INR 0.9-1.3 no therapy Standardized ratio to
2-3 taking warfarin evaluate blood clotting and 2-3 taking warfarin evaluate blood clotting and
<0.5 high risk of clot warfarin therapy <0.5 high risk of clot warfarin therapy
> 5 high risk of bleeding > 5 high risk of bleeding

Potassium 3.5-5 mEq/L Nerve and muscle function, Potassium 3.5-5 mEq/L Nerve and muscle function,
fluid balance. fluid balance.

PT 11-15 s Evaluates clotting time, PT 11-15 s Evaluates clotting time,

along with PTT. Extrinsic along with PTT. Extrinsic
pathways pathways

PTT 60-80 s Evaluates clotting time. PTT 60-80 s Evaluates clotting time.
Evaluates heparin therapy. Evaluates heparin therapy.

Sodium 135-145 mEq/L Maintains body fluid Sodium 135-145 mEq/L Maintains body fluid
volume . volume .

Urine Specific gravity 1.003-1.030 Measures urine concentra- Urine Specific gravity 1.003-1.030 Measures urine concentra-
tion tion