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Notes:

Proactive Risk Management: The focus is on spotting early warning signs of patient deterioration and making life-saving decisions before a crisis escalates. Nurses must be vigilant and act quickly to prevent further harm.

ABCs (Airway, Breathing, Circulation): The foundation of every clinical decision. Airway issues must be addressed immediately, as nothing else matters if the airway is compromised. This rule is paramount in any acute care scenario and is a key focus for NCLEX questions.

Baseline Comparison: The importance of knowing a patient’s baseline to spot abnormal changes. A 10% drop in blood pressure or a heart rate that is significantly higher than normal could indicate early shock or other life-threatening issues. Nurses must recognize these subtle changes to intervene in time.

Delegation vs. Assessment: Delegation should be used for routine tasks (e.g., turning a patient or taking vitals), but critical assessment and decision-making are the nurse’s responsibility. Nurses are the "clinical detectives" responsible for interpreting data and acting on it.

Diagnostic Procedures and Risk Reduction: Preparation is key for minimizing risk during diagnostic procedures like radiographic studies. Always verify informed consent, confirm the patient's identity and allergies, and check baseline vitals. Special attention is needed for procedures involving contrast dye, as iodine allergies can lead to life-threatening anaphylaxis.

Cardiac Catheterization and Bleeding Risk: After cardiac catheterization, strict bed rest is required to prevent bleeding at the insertion site. Nurses must monitor for signs of bleeding, such as changes in distal pulses or pain. Use the "six Ps" (Pain, Pallor, Paresthesia, Paralysis, Pulselessness, and Poikilothermia) to assess for compromised circulation.

Recognizing Retroperitoneal Bleeding: Subtle signs of retroperitoneal hemorrhage include back or flank pain and a gradual drop in hematocrit levels. This condition can be life-threatening if not caught early.

Bronchoscopy and Aspiration Risk: Aspiration is a major concern after a bronchoscopy. Nurses should position the patient on their side until they are fully awake and the gag reflex returns to prevent aspiration.

Post-Procedure Concerns: Nurses must monitor patients post-sedation, especially after procedures like bronchoscopy or lumbar puncture. The main concern is aspiration or bleeding. In lumbar punctures, checking coagulation studies is critical to avoid spinal hematoma.

Critical Lab Values: Key lab values that require immediate attention include:

Potassium: Levels below 2.5 or above 6.5 can cause deadly arrhythmias.

Sodium: Levels below 120 or above 160 increase the risk of seizures or coma.

INR: A high INR (above 4-5) is a bleeding risk, particularly for patients on anticoagulants like warfarin.

Platelets: Levels below 20,000–50,000 increase the risk of spontaneous bleeding.

pH: A pH below 7.2 or above 7.6 indicates a serious metabolic problem and demands immediate intervention.

Acid-Base Imbalances: Nurses must identify whether the problem is respiratory or metabolic by analyzing the pH, CO2, and bicarbonate levels. Severe hypocalcemia, indicated by peak T-waves on the EKG, requires immediate treatment with calcium gluconate to protect the heart.

Post-Surgical Bleeding: In post-operative patients, especially those undergoing procedures like thyroidectomy, rapid swelling or a hoarse voice could indicate a hematoma. Immediate intervention is required to secure the airway.

Malignant Hyperthermia: A life-threatening reaction to anesthesia characterized by rapid temperature rise and severe muscle rigidity. This requires immediate administration of dantrolene to prevent fatal outcomes.

Wound Complications: Nurses must be prepared for serious complications like dehiscence or evisceration. Immediate action includes covering the wound with sterile moist saline dressings and calling for urgent surgical intervention.

Blood Transfusion Reactions: The first action in response to a transfusion reaction is to stop the transfusion immediately. Common signs of a hemolytic reaction include fever, flank pain, and dark urine. Nurses must flush the IV line with saline and notify the provider and blood bank.

Refeeding Syndrome and TPN Risks: For patients receiving total parenteral nutrition (TPN), rapid nutritional replenishment in malnourished patients can lead to refeeding syndrome, causing dangerous shifts in electrolytes (phosphate, potassium, magnesium). Close monitoring of these labs is critical to prevent life-threatening arrhythmias.

Critical Thinking in Action: Nurses must distinguish between conditions that require immediate attention versus those that pose a future risk. For example, a hematoma after surgery represents an immediate airway risk, whereas a potential DVT could evolve into a PE over time.

Need to reach out? Send an email to Brooke at [email protected]