ABG’s—It’s All in the Family

Newly Revised, Updated, & Peer Reviewed: November 20, 2009

By Cyndi Cramer, BA, RN, OCN, PCRN

RealNurseEd.com

Revised and Updated by: Jackie Gilbert, BA, MS, BS, PCRN

and Tracy Thomas. BSN, CCRN, PCRN

Peer Reviewed by:

Lacey Lewis, RN, PCRN and Paul Pearson, RN, PCRN

and Kimatha Wolfley, RN

3.0 Contact Hour Self Learning Module

Objectives:

  1. Identify the components of the ABG and their normal ranges
  2. Interpret ABG values and determine the acid base abnormality given
  3. Identify the major causes of acid base abnormalities
  4. Describe symptoms associated with acid base abnormalities
  5. Describe interventions to correct acid base abnormalities
  6. Identify the acceptable O2 level per ABG and Pulse Oximetry
  7. Identify four causes of low PaO2

I. The Background Stuff

The body tries to maintain homeostasis with the Acid Base balance using acids and bases contained within the body. Each acid and base counter balances with each other (the alkaline part of your ABG). The body enzymes cannot work outside of the balance. The ABG is an arterial Blood measurement of this acid base status.

  • The Respiratory System (Acid); 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 ALKLAOSIS
      2. If you decrease your respiratory rate (hypoventilation) you retain CO2 (acid) therefore increasing your CO2 (acid)—giving you ACIDOSIS
  • The Renal System (Base); the kidneys rid the body of the nonvolatile acids H+ (hydrogen ions) and maintain a constant bicarb (HCO3). Bicarbonate is the body’s base
      1. You have Acidosis when you have excess H+ and decreased HCO3- causing a decrease in pH.
      2. The Kidneys try to adjust for this by excreting H+ and retaining HCO3- base.

        The Respiratory System will try to compensate by increasing ventilation 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

  • Compensation
      1. The respiratory system can effect a change in 15-30 minutes

      2. The renal system takes several hours to days to have an effect.

    II. The Big Four

    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 (distension)

    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+ (potassium leaves

    the cell to replace the H+ buffers leaving the cell)

    3. Treatment

    a. Physically stimulate the patient 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)

    d. Reversal of sedatives and narcotics

    e. Antibiotics for infections

    f. Diuretics for fluid overload

    (NOTE: beware of NaHCO3- sodium bicarbonate—can compensate and cause metabolic alkalosis. Also, if patient has been hypoxic and this is a lactic acidosis; NaHCO3- can be dangerous)

    Respiratory Alkalosis: pH > 7.45 (Normal: 7.35 - 7.45) CO2 < 35 (Normal: 35 – 45)

        Causes: Alveolar Hyperventilation
      1. Psychogenic (fear, pain, anxiety)
      2. CNS stimulation (brain injury, ETOH, early salicylate poisoning, brain tumor)
      3. Hypermetabolic states (fever, thyrotoxicosis)
      4. Hypoxia (high altitude, pneumonia, heart failure, pulmonary embolism)
      5. Mechanical overventilation (ventilator rate too fast)
        Signs and Symptoms
      1. Heachache
      2. Vertigo
      3. Paresthesias (numb fingers /toes, circumoral, carpal pedal spasms and tetany)
      4. Tinnitus (ringing in the ears)
      5. Electrolyte abnormalities (decreased Ca+, K+)
        Treatment (treat the underlying cause)
      1. Sedatives or analgesics
      2. Correction of hypoxia (possible diuretics, mechanical ventilation to also decrease respiratory rate and decrease the tidal volume)
      3. NOTE: patients with brain injury may need hyperventilation

      4. Antipyretics for fever
      5. Treat hyperthyroidism
      6. Breathe into a paper bag for hyperventilation
      Metabolic Acidosis pH < 7.35 (Normal: 7.35 - 7.45) HCO3- < 22 (normal: 22 – 26)

        Causes: Increased H+, excess loss of HCO3-
      1. Overproduction of organic acids (starvation, ketoacidosis, increased catabolism)
      2. Impaired renal excretion of acid (renal failure)
      3. Abnormal loss of HCO3- (diarrhea, biliary fistula, Diamox)
      4. Ingestion of acid (salicylate overdose, oral anti-freeze)
        Signs and Symptoms
      1. CNS depression (confusion to coma)
      2. Cardiac Dysrhythmias (elevated T wave, wide QRS to ventricular standstill)
      3. Electrolyte abnormalities (elevated K+, Cl-, Ca2+)
      4. Flushed skin (arteriolar dilitation)
      5. Nausea
        Treatment (Treat the underlying cause)
      1. NaHCO3- (sodium bicarbonate) based on ABGs only and with caution
      2. IV fluids and insulin for DKA
      3. Dialysis for renal failure
      4. Antibiotics, increased nutrition for tissue catabolism
      5. Increased cardiac output and tissue perfusion for low CO states
      6. Rehydrate, monitor I and O
      7. Treat dysrhythmias, support hemodynamic and respiratory status
      Metabolic Alkalosis pH > 7.45 (Normal: 7.35 - 7.45) HCO3- > 26

        Causes: Loss of H+ or increased HCO3-
      1. Loss of K+ (diarrhea, vomiting)
      2. Ingestion of large amounts of bicarbonate (antacids, resuscitation)
      3. Prolonged use of diuretics (distal tubule lose ability to reabsorb Na+ and Cl- therefore NaCl); Ammonia is in the urine and then binds with H+
        Signs and Symptoms: similar to the disease process
      1. Diaphoresis
      2. Nausea and Vomiting
      3. Increase neuromuscular excitability (Ca2+ binds with protein)
      4. Shallow breathing (respiratory compensation)
      5. EKG changes (increased QT, sinus tachycardia)
      6. May also see confusion progressing to lethargy to coma
      7. Electrolyte abnormality (decreased Ca2+), normal or decreased K+, increased base excess on the ABG
        Treatment: Treat the underlying cause
      1. Replace potassium (KCl) losses in 0.9% NaCl (rehydrates and increases HCO3- excretion)
      2. Diamox (acetazolamide, increases HCO3-excretion)
      3. Monitor neuro status, re-orient, seizure precaution, monitor I and O

    III. The Land of the ABG**

    (**based upon a concept by Laura Gasparis Vonfrolio, RN, PhD)

    Once upon a time there was a land known as ABG

    Everyone there was related with only a limited number of names for the population.

    They were also very polite and had their own etiquette for learning each other’s names.

    Now I would like to introduce you to your patient. Let’s figure out what her name is.

    All of the people in the land of ABG have a first name, a middle name, and a last name.

    You just have to look at them one name at a time.

      The Last Name
    1. First, look at her pH (normal is 7.35 - 7.45)
    2. If her pH is < 7.35; her name is ACIDOSIS
    3. If her pH is > 7.45; her last name is ALKALOSIS

    (NOTE: To have an absolutely perfect last name; her pH needs to be 7.40. So, keep in mind that if her pH is 7.35 - 7.39 she’s thinking about marrying into the ACIDOSIS family. If her pH is 7.41 - 7.45 she’s thinking about marrying into the ALKALOSIS family)

      The First Name

    Now that you know your patient’s last name, you would like to also learn her first name.

      1. Look at her pH again.
      2. If it is 7.35 - 7.45 (normal) then her first name is COMPENSATED.
      3. If the pH is < 7.35 or > 7.45 then her first name is UNCOMPENSATED.
      The Middle Name

    Now that you know your patient’s first and last name, you would like to know her

    middle name.

    Name Alert: These people are all related and you have many patients with the same

    first and last name. A middle name will give you more information.

    First you need to look at the CO2 and HCO3-. Remember : normal CO2 35 - 45; and

    HCO3- 22 - 26.

    1. The middle name will either be Respiratory or Metabolic.

    2. If the CO2 is < 35 or > 45 her middle name is RESPIRATORY.

    3. If the HCO3- is < 22 or > 26; her middle name is METABOLIC.

    The Family Feud

    1. pH and HCO3- are "kissin’ cousins" they like to go in the same direction

    2. CO2 is the "black sheep" pH runs the opposite direction when it sees him

    coming.

    THEREFORE:

    3. Decreased pH with decreased HCO3-: ACIDOSIS

    4. Increased pH with increased HCO3-: ALKALOSIS

    5. Decreased pH with increased CO2-: ACIDOSIS

    6. Increased pH with decreased CO2-: ALKALOSIS

    Let’s Practice

    The following ABG’s were all given to you by your respiratory therapist.

    EXAMPLE ONE:

    pH = 7.60; CO2 = 30; HCO3- =22

    What is her last name?
    What is her first name?
    What is her middle name?
    You have now been introduced to UNCOMPENSATED RESPIRATORY ALKALOSIS

    EXAMPLE TWO:

    pH = 7.35; CO2- = 50; HCO3- = 25

    What is her last name?
    What is her first name?
    What is her middle name?
    You have now been introduced to COMPENSATED REPIRATORY ACIDOSIS

    EXAMPLE THREE:

    pH = 7.55; CO2- = 40; HCO3- = 30

    What is her last name?
    What is her first name?
    What is her middle name?
    You have now been introduced to COMPENSATED METABOLIC ALKALOSIS

    EXAMPLE FOUR:

    pH = 7.35; CO2- = 45; HCO3- = 21

    What is her last name?
    What is her first name?
    What is her middle name?
    You have now been introduced to COMPENSATED METABOLIC ACIDOSIS

    Now practice doing some yourself:

    1. Choose from the below answer key to answer these questions:

    Answer Key:

    a. Compensated respiratory acidosis
    b. Compensated metabolic alkalosis
    c. Compensated metabolic acidosis
    d. Uncompensated metabolic acidosis
    e. Compensated respiratory alkalosis
    f. Compensated metabolic alkalosis
    g. Compensated respiratory acidosis
    h. Uncompensated metabolic alkalosis
    i. Compensated respiratory acidosis
    j. Uncompensated respiratory alkalosis
    1. pH = 7.31 PaCO2 = 48 HCO3- = 24
    2. pH = 7.47 PaCO2= 45 HCO3- = 33
    3. pH = 7.20 PaCO2 = 36 HCO3- = 14
    4. pH = 7.50 PaCO2 = 29 HCO3- = 22
    5. pH = 7.23 PaCO2 = 59 HCO3- = 22
    6. pH = 7.50 PaCO2 = 38 HCO3- = 30
    7. pH = 7.40 PaCO2 = 41 HCO3- = 25.5
    8. pH = 7.49 PaCO2 = 44 HCO3- = 34
    9. pH = 7.35 PaCO2 = 40 HCO3- = 23
    10. pH = 7.60 PaCO2 = 33 HCO3- =23

    Now try some harder ones:

    1. Choose from the below answer key for these questions:

    Answer Key:

    a. Compensated respiratory acidosis
    b. Compensated metabolic alkalosis
    c. Compensated metabolic acidosis
    d. Uncompensated metabolic acidosis
    e. Compensated respiratory alkalosis
    f. Compensated metabolic alkalosis
    g. Compensated respiratory acidosis
    h. Uncompensated metabolic alkalosis
    i. Compensated respiratory acidosis
    j. Uncompensated respiratory alkalosis

    1. pH = 7.36 PaCO2 = 56 HCO3- = 26
    2. pH = 7.43 PaCO2 = 32 HCO3- = 29
    3. pH = 7.35 PaCO2 = 31 HCO3- = 18.1
    4. pH = 7.19 PaCO2 = 45 HCO3- = 18.1
    5. pH = 7.44 PaCO2 = 47 HCO3- = 26
    6. pH = 7.42 PaCO2 = 35 HCO3 – = 27
    7. pH = 7.36 PaCO2 = 26 HCO3 - =26
    8. pH = 7.48 PaCO2 = 37 HCO3- = 29
    9. pH = 7.35 PaCO2 = 38 HCO3- = 26
    10. pH = 7.60 PaCO2 = 33 HCO3- = 26

    The prefix to the name:

    You have been introduced to the married name of the ABG now you are to be introduced to the full married name of the ABG. (Like Ms. or Mrs.)

    1. Partially: This describes when you have abnormalities in both systems and your pH is abnormal. This shows that one system has tried to compensate for the other but is not yet successful.
    2. Completely: This describes when abnormalities in both systems occur and your pH is normal. This shows that one system has been able to compensate for the other
    3. Now, we can describe the FULL MARRIED NAME.
      1. pH = 7.09 PaCO2 = 50 HCO3- = 30
      2. pH = 7.21 PaCO2 = 55 HCO3- = 28
      3. pH = 7.67 PaCO2 = 60 HCO3- = 45
      4. pH = 7.45 PaCO2 = 33 HCO3- = 20
      5. pH = 7.01 PaCO2 = 20 HCO3- = 10
      6. pH = 6.9 PaCO2 = 65 HCO3- = 19
      7. pH = 7.35 PaCO2 = 48 HCO3- = 30
      8. pH = 7.48 PaCO2 = 25 HCO3- =12
      9. pH = 7.12 PaCO2 = 30 HCO3- = 10
      10. pH = 7.58 PaCO2 = 22 HCO3- = 20

      V. O2 STANDS ALONE

      Did you notice that I haven’t mentioned O2?

      The O2 number has nothing to do with your acid-base ABG interpretation!

        What does the PaO2 mean?
        What is saturation?

      Note: In Carbon Monoxide Poisoning, the Hgb is saturated with Carbon Monoxide. Although the patient is hypoxemic, it is because there is no room on the Hgb for O2 to be carried – the Saturation looks good because it can’t distinguish between the two.

        What are some causes of low PaO2?
        Why do we look at Base Excess (BE)?

      Can we only be PARTIALLY compensated?

      LET’S PRACTICE:

    1. pH 7.34, PCO2 34, HCO3- 18.6, BE -6, PO2 86%

    2. pH 7.58, PCO2 48, HCO3 48, BE +22, PO2 59%

    3. pH 7.29, PCO2 78, HCO3- 36, BE +7, PO2 32%

    4. pH 7.45, PCO2 28, HCO3- 20, BE -3, PO2 66%

    5. pH 7.30, PCO2 31, PO2 77, HCO3- 18;

    For Additional Practice Problems, Click Here:

    VI. If you are ready for contact hours—you have to take the test. You can practice first here: Practice Test
    which will open a new window. When you are done just close the new window.

    VII. Or, to go directly to the post test below just scroll down.

    Note: I MUST have your license number & state if you want the CE + you will need to fill out the evaluation to keep the state of Florida happy!!

    VII. Check out the "CHEAT SHEET"

    If you would like a cheat sheet as a reminder for ABGs—just print this out: CLICK HERE

    REFERENCES

    Corning, HS & Bryant, SL. Mosby’s Respiratory Care PDQ. Mosby, 2005.

    Hennessey, I & Japp, A. Arterial blood gases made easy. Churchill Livingstone, 1st edition. 2007.

    Hogan, MA & Wane, D. Fluids, electrolytes, and acid –base balance. Pearson Education, Inc., 1st edition. 2003.

    Malley, WJ. Clinical blood gases: Assessment & Intervention. Saunders, 2nd edition. 2004.

    Morton, PG, Fontaine, DK, Hudak, CM, Gallo, BM. Critical care nursing: A holistic approach. Lippincott, Williams, and Wilkins, 8th edition. 2005.

    Oakes, D. Arterial blood gas pocket guide. Respiratorybooks.com. 2009.

    Springhouse. Respiratory care made incredibly easy. Lippincott, Williams & Wilkins. 2004.

    Post Test

    You have to take this post test, fill in your name, license number and state, and do the evaluation to make the state of Florida happy and you will get your CE which will come in the body of a return e-mail within the next few days!!

    "ABG – IT’S ALL IN THE FAMILY" Post Test

    1. Mr. M is a 65-year old male admitted with a decreased level of consciousness (LOC). He has a history of chronic bronchitis and heart failure. His vital signs are: Temp-102, HR-104, RR-28 and shallow, BP-90/60. ABG results are as follows:

    pH 7.2
    PCO2 75 mmHg
    HCO3- 26 mEq/L

    What is the acid base disturbance?
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    2. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    3. What are some causes of this disorder?
    Vomiting, diarrhea, prolonged diuretics
    Pain, fever, hyperventilation
    Pneumonia, hypoventilation, pneumothorax
    Renal failure, ASA overdose, starvation, ketoacidosis

    4. What are the interventions for this disorder?
    IV fluids (IVF), insulin, NaHCO3 based on ABG’s only
    Vigorous pulmonary toilet, antibiotics, diuretics, mechanical ventilation
    Sedatives or analgesics, breathe into paper bag, mechanical ventilation to decrease rate.
    Potassium replacement, Diamox

    5. Mrs. G., who has congestive heart failure (CHF), has been having diarrhea for three days. You have noticed some LOC changes and she is breathing shallowly. The doctor orders ABG’s:

    pH 7.44
    PCO2 50 mmHg
    HCO3- 31 mEq/L

    What is the acid base disturbance?
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    6. Is this compensated or uncompensated?
    Compensated
    Uncompensated

    7. What are some causes of this disorder?
    Vomiting, diarrhea, prolonged diuretics
    Pain, fever, hyperventilation
    Pneumonia, hypoventilation, pneumothorax
    Renal failure, ASA overdose, starvation, ketoacidosis

    8. What are the interventions for this disorder?
    IVF & insulin, NaHCO3- based on ABG’s only
    Vigorous pulmonary toilet, antibiotics, diuretics, mechanical ventilation
    Sedatives or analgesics, breathe into paper bag, mechanical ventilation to decrease rate
    K+ replacement, Diamox

    9. Ms. P., a 22-year old female, is admitted with an acute onset of fever, chills, and Rt. upper quadrant pain.
    Her vital signs are: T=99.6, P=125, RR=32, BP=140/84.
    Her ABG results are:

    pH 7.53
    PaCO2 30 mmHg
    HCO3- 22 mEq/L

    What is the acid base disturbance?
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    10. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    11. What are some causes of this disorder?
    Vomiting, diarrhea, prolonged diuretics
    Pain, fever, hyperventilation
    Pneumonia, hypoventilation, pneumothorax
    Renal failure, ASA overdose, starvation, ketoacidosis

    12. What are the interventions for this disorder?
    IVF & insulin, NAHCO3- based on ABG’s only
    Vigorous pulmonary toilet, antibiotics, diuretics, mechanical ventilation
    Sedatives or analgesics, breathe into paper bag, mechanical ventilation to decrease rate.
    K+ replacement, Diamox

    13. Mrs. D is a 45-year old female admitted with a history of diabetes.
    She has a temperature of 101.8, P=110, RR=30, BP=90/70.
    Labs are drawn and reveal a glucose of 780 mg/dl, positive ketones, and the following ABG’s:

    pH 7.25
    PaCO2 35 mm Hg
    HCO3- 18 mEq/L

    What is the acid base disturbance?
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    14. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    15. What are some causes of this disorder?
    Vomiting, diarrhea, prolonged diuretics
    Pain, fever, hyperventilation
    Pneumonia, hypoventilation, pneumothorax
    Renal failure, ASA overdose, starvation, ketoacidosis

    16. What are the interventions for this disorder?
    IVF & insulin, NAHCO3- based on ABG’s only
    Vigorous pulmonary toilet, antibiotics, diuretics, mechanical ventilation
    Sedatives or analgesics, breathe into a paper bag, mech. vent. to decrease rate
    K+ replacement, Diamox

    17. Mr. J calls you to his room with a complaint of shortness of breath.
    His SaO2 is 89% on room air.
    He has rhonchi in all lobes and a temperature of 101,
    P=122, RR=36, BP=160/92.
    RT draws ABG’s with the following results:

    pH 7.33
    PaCO2 72 mmHg
    HCO3- 24

    What is the acid base disturbance?
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    18. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    19. Is his PaO2 normal?
    No
    Yes

    20. Under what SaO2 does the PaO2 significantly decrease?
    70%
    95%
    85%
    92%

    21. The PaO2 measures?
    Hypoxia
    Anemia
    Hypoxemia
    Azotemia

    22. How can you tell that your ABG is compensated?
    The CO2 is 35 - 45
    The HCO3- is 22 - 26
    The pH is 7.35 - 7.45
    The O2 is > 90

    23. What are some causes of low PaO2?
    Low supply of O2
    Decreased cardiac output
    Anemia
    Carbon monoxide poisoning
    All of the above

    24. Interpret the following ABG’s:
    pH 7.47, CO2 30, HCO3- 24
    Metabolic acidosis
    Metabolic alkalosis
    Respiratory acidosis
    Respiratory alkalosis

    25. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    26. pH 7.30, CO2 75, HCO3- 22:
    Respiratory Acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    27. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    28. pH 7.36, CO2 32, HCO3- 20
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic alkalosis
    Metabolic acidosis

    29. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    30. pH 7.48, CO2 46, HCO3- 28
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    31. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    32. pH 7.38, CO2 50, HCO3- 27
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis
    Respiratory acidosis

    33. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

    34. pH 7.50, CO2 35, HCO3- 32
    Respiratory acidosis
    Respiratory alkalosis
    Metabolic acidosis
    Metabolic alkalosis

    35. Is this Compensated or Uncompensated?
    Compensated
    Uncompensated

     
     
     

    Participant Self-Learning Program Evaluation

    The information below is required before contact hours can be given.

    Program Title:
     

    "ABGs--It's All In The Family"

    Date: (month / day / year)

    Nursing License Number:

    State

    Name:

    Complete E-mail address ( example: nurse@aol.com ) :

    Your feedback is valued and will assist in improving this program. Please explain ratings of 2 or 1.

    Ratings: 5 = Excellent 4 = Very Good 3 = Good 2 = Fair 1 = Poor

    1.   Objectives of program were clear.54321

    2.   Objectives were met. 1

    3.   Time allotted was adequate 5431

    4.   Author’s Knowledge of  subject matter5431

    5.   Efficient Method of Instruction54321

    6.   Provided for material review 531

    7.   Program expectations satisfied 51

    8.   Organization/readability of program 531

    9.   Test correlated with objectives41

    10.  Would you recommend this Self-Learning Program to another student?yesno

    11. One contact hour should take approximately 50-60 minutes to complete.
    If you read all the material, did the practice problems, and took both tests - Do you
    feel this program was in the 3 hour range? yesno

    11a. If not - please explain.

    12. What could have improved the program?

    13. Any suggestions for future Self-Learning Programs?

    14. Would you utilize another Self-Learning experience by this instructor?yesno

          14a. Why or why not?

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