The Super Nurse Podcast

Check out ThinkLikeANurse.orgCOMPREHENSIVE NOTESCore Difference: DKA vs HHSDKA (Type 1 diabetic, absolute insulin deficiency)No insulin → body burns fat → ketones formed → metabolic acidosisDeep, rapid Kussmaul respirationsTotal body potassium depleted though serum may appear highState of starvation + dehydrationHHS (Type 2 diabetic, relative insulin deficiency)Some insulin remains → prevents ketones → no significant acidosisExtreme hyperglycemia (often 600–1200+)Severe dehydration + high serum osmolalitySlow onset, often in older adultsDiagnostic MarkersDKA Diagnostic TriadHyperglycemia > 250Metabolic acidosispH < 7.30Bicarb < 18Anion gap elevatedKetones moderate to large (blood or urine)HHS Diagnostic MarkersExtreme hyperglycemia > 600 (often > 1000)Serum osmolality > 320Minimal or no ketones, pH > 7.3DKA Treatment Priorities (FIK Sequence)This is a major NCLEX priority sequence.F – Fluids firstSevere dehydration: 4–6 liters lostStart aggressive normal salineAbout 1 liter in the first hourGoal: restore perfusion and blood pressure quicklyI – Insulin secondOnly after fluids have begunRegular insulin IV bolus → insulin infusionCritical NCLEX rule: Check potassium FIRSTK – Potassium lastInsulin drives potassium into cells → serum potassium drops fastIf potassium < 3.3 → HOLD insulin and replace potassium immediatelyBegin potassium replacement once potassium < 5.2 AND urine output is presentWhen glucose reaches 200–250Switch to D5 ½ NSPurpose: prevent hypoglycemia while continuing insulin to clear ketones and acidosisHHS Treatment PrioritiesFluids (most critical)Fluid loss often 9–12 litersMore aggressive initial resuscitation than DKAStart 0.9% normal saline, often 1–2 liters in the first hourSlow, careful insulinLower dose: ~0.05–0.1 units/kg/hrBegin only after fluid resuscitationTarget glucose drop: 50–70 per hourPurpose: prevent cerebral edema, caused by rapid osmotic shiftsPrevent thrombosis (HHS-specific)Hyperosmolar blood → massive thrombosis riskEarly low molecular weight heparin unless contraindicatedFluid transitionSwitch fluids when glucose reaches 250–300Use 0.45% sodium chlorideHigh-Yield ScenariosScenario 1: DKA with potassium 3.0Priority:Start normal salineHold insulinImmediate aggressive potassium replacementOnce potassium rises above 3.3 → start insulin infusionNCLEX trap: Giving insulin first.Scenario 2: HHS elderly patient, glucose 1250, osmolality 400Priority:Aggressive normal salineInsert Foley catheter for hourly urine outputStart LMWH for clot preventionDelay insulin until hydration improvesThen start low-dose insulin infusion slowlyPrevention and Patient EducationWho is high risk for DKA?Type 1 diabeticsYoung adultsThose experiencing diabetes burnoutPatients omitting insulin dosesAny illness that increases metabolic demandDischarge teaching essentialsSick-day rules: Never skip insulinCheck blood glucose 4–10 times/dayCheck ketones when glucose > 250Evolving Role of TechnologyContinuous glucose monitors (e.g., Eversense 365)Automated insulin delivery systemsOmnipod 5iLet / Twist systemThese systems significantly reduce DKA admissions (40–60%)Nurses increasingly become educators and system managers rather than crisis responders Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Check out thinklikeanurse.orgComprehensive Notes Core ConceptBoth conditions revolve around one hormone: ADH, the body’s water-saving signal.SIADH: Too much ADH → body holds water (soaked inside)DI: Not enough ADH or kidneys ignore ADH → body loses water (dry inside)The blood and urine move in opposite directions in each disorder.SIADH — “Soaked Inside, All Diluted”What HappensADH is high → kidneys save waterBlood becomes dilutedUrine becomes concentratedClassic CausesSmall cell lung cancer (ectopic ADH)Head traumaPituitary surgerySSRIsCarbamazepine, vincristineSevere pneumonia, meningitisSevere pain or nauseaHallmark LabsLow sodiumLow serum osmoHigh urine specific gravityHigh urine osmoTypical Patient PictureConfusion, headache, lethargyWeight gain (one kilogram equals one liter held)High blood pressurePuffy face or eyesNot thirstyVery low urine output, dark concentrated urinePriority InterventionsStrict fluid restrictionDaily weightsNeuro checks every few hoursSeizure precautions (especially when sodium drops below one twenty)Critical MedicationHypertonic saline (three percent) for seizures or very low sodiumMust use a central lineMust correct sodium slowly (no more than eight to twelve points in twenty-four hours)Major WarningCorrecting sodium too fast risks central pontine myelinolysis, an irreversible brainstem injury.Never DoNever give hypotonic fluidsNever give normal salineNever increase free waterDiabetes Insipidus — “Dry Inside, All High”What HappensLittle or no ADH signalKidneys dump waterBlood becomes concentratedUrine becomes extremely diluteTwo TypesCentral DIPituitary does not make ADHCauses: head trauma, brain tumors, pituitary surgeryNephrogenic DIKidneys ignore ADHCauses: lithium, some antibiotics, chronic high calciumHallmark LabsHigh sodiumHigh serum osmoVery low urine osmoVery low specific gravityTypical Patient PictureIntense thirstClear water-like urineTen to twenty liters of urine per dayRapid weight lossTachycardia, low blood pressureSigns of hypovolemic shockPriority InterventionsAggressive fluid replacement (D5W or free water)Hourly intake and outputDaily weightsWatch closely for shockStopping the Water LossCentral DI: Give desmopressin (DDAVP)Nephrogenic DI:Stop lithium or offending drugGive a thiazide diuretic (paradox: triggers earlier sodium and water reabsorption)Major WarningNever fluid restrict DI — causes immediate circulatory collapse.SIADH vs DI: The Instant EN-KLEX PatternThink Like a Nurse Bow-Tie PatternLow sodium + high urine osmo → SIADHAction: fluid restrictSafety: neuro checks, seizure precautionsHigh sodium + low urine osmo → DIAction: free water, D5W, desmopressinSafety: hourly intake and output, watch for shockBedside PearlIf a post-pituitary surgery patient suddenly puts out large amounts of clear urine and their sodium is rising past one forty-five:→ Stop what you’re doing and call the provider immediately.This is a DI crisis until proven otherwise. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

This episode breaks down three of the most dangerous respiratory emergencies nurses face: ARDS, cardiogenic pulmonary edema, and tension pneumothorax. Using clear bedside cues and rapid-action frameworks, you learn how to spot these crises early, understand the physiology driving them, and take the immediate steps that prevent collapse. From pink frothy sputum to tracheal deviation to refractory hypoxia, this conversation turns complex pathology into a simple action plan rooted in airway-first priorities, lung-protective strategies, and critical “never delay” rules. By the end, you’ll know exactly how to differentiate a mechanical problem, a cardiac overload problem, and an inflammatory lung problem—and what to do the moment each one appears. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Check out thinklikeanurse.org for more#Comprehensive Notes##I. OverviewFocus: 6 electrolytes + 4 acid–base disordersGoal: Know one classic sign + one lifesaving intervention for eachNCLEX weight: High (8–16 questions across categories)Foundational rule: Always assess volume status first — dry vs overloaded guides almost every interventionII. SodiumA. HyponatremiaClassic sign: seizures (especially when levels plunge)Why: water shifts into brain → swelling → seizure riskLifesaving action: 3% hypertonic saline, rapid bolus for active seizureAdditional pearls:Chronic hyponatremia (e.g., “tea and toast” elderly patient): correct slowly to prevent osmotic demyelination syndromeLimit correction to 6–8 points in 24 hours once stableB. HypernatremiaClassic sign: intense thirst + confusionWhy: brain cells shrink from dehydrationLifesaving action: give free water (D5W IV, oral, or tube)Rule: correct slowly to prevent cerebral edemaIII. PotassiumA. HypokalemiaClassic sign: U-waves on ECGLifesaving action: potassium replacementSafety rules:Never exceed 10–20 per hour through a peripheral lineOral preferredReplace magnesium first—low magnesium prevents potassium correctionB. HyperkalemiaThe most urgent electrolyte emergencyClassic sign: tall peaked T-waves → wide QRS → sine-wave → cardiac arrestThree-step lifesaver sequence:Stabilize: calcium gluconate protects myocardiumShift: insulin + dextrose (or high-dose albuterol) moves potassium into cellsRemove: kayexalate, loop diuretics, or dialysisIV. Calcium & MagnesiumA. HypocalcemiaClassic signs:Chvostek sign (facial twitch with cheek tap)Trousseau sign (carpal spasm with BP cuff)Lifesaving action: slow IV calcium gluconateRisk of fast push: bradycardia, severe hypotensionB. HypermagnesemiaOften renal failure or magnesium infusionsClassic signs:Profound hypotensionLoss of deep tendon reflexes (areflexia)Lifesaving action:Stop magnesiumGive calcium gluconate to counteract cardiac depressionV. Acid–Base DisordersInterpretation Rule:pH + bicarbonate same direction → metabolicpH + CO₂ opposite directions → respiratoryClinical principle:Treat the patient before the numberVolume status affects everything.A. Respiratory AcidosisCause: CO₂ retention from hypoventilation (opioids, COPD flare)Signs: sleepiness, poor arousalLifesaving action: improve ventilation — stimulate, bilevel support, or intubateB. Respiratory AlkalosisCause: hyperventilation (pain, anxiety, early sepsis, PE)Signs: tingling around mouth and fingers, lightheadedLifesaving action: treat cause — calm anxiety, treat PE, manage painC. Metabolic AcidosisClassic sign: Kussmaul respirations (deep, rapid breathing)DKA clue: fruity acetone breathMnemonic for causes: MUDPILESMethanolUremiaDKAPropylene glycolIronLactic acidosisEthylene glycolSalicylatesLifesaving action: treat underlying causeDKA → insulinLactic acidosis → fix shockGive bicarbonate only when pH < 7.1 and patient is crashing.D. Metabolic AlkalosisCause: loss of stomach acid (vomiting, NG suction)Often causes: secondary low potassiumLifesaving action: normal saline + potassiumChloride allows kidneys to excrete excess bicarbonatePotassium replaces lossesConsider acetazolamide in severe cases.VI. Practice Scenarios (High-Yield NCLEX Style)1. Vomiting × 3 dayspH high + bicarbonate high → metabolic alkalosisInterventions: normal saline + potassium; consider acetazolamide2. Severe DKApH extremely low + bicarbonate low → metabolic acidosisFirst action: start regular insulin infusion3. Chronic COPDpH low + CO₂ high + bicarbonate high → partially compensated respiratory acidosis Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Visit thinklikeanurse.orgComprehensive Episode Notes1. What Shock Really IsCore definition: inadequate tissue perfusion, leading to anaerobic metabolism, rising acid, cellular hypoxia, and eventual organ failure.All shock types follow the same three-stage progression:Stage 1: Compensated – tachycardia, tachypnea, cool pale skin, anxiety, decreased urine output; BP may still look normal.Stage 2: Decompensated – severe tachycardia, severe tachypnea, drop in BP, narrowed pulse pressure, mental status changes, oliguria/anuria, metabolic acidosis.Stage 3: Irreversible – refractory hypotension, multiorgan failure, disseminated intravascular coagulation, poor response to pressors or fluids.2. The Big Three Shock CategoriesA. Hypovolemic Shock — “The Empty Tank”Causes: bleeding, trauma, burns, dehydration, massive fluid shifts (DKA, vomiting, diarrhea).Key assessment:Pale, cool, clammyFlat neck veinsThready pulsesLow urine outputLab clues:Low hemoglobin/hematocrit (bleeding)High hemoglobin/hematocrit (hemoconcentration from dehydration)BUN-to-creatinine ratio over 20:1 → prerenal dehydrationPriority actions:Two large-bore IVs, rapid fluid resuscitationBlood products if bleedingKeep patient warm; control source of fluid lossB. Cardiogenic Shock — “The Broken Pump”Causes: massive heart attack, myocarditis, pulmonary embolism, cardiac tamponade.Key assessment:Cold + wetJugular vein distentionCrackles, pulmonary edema, pink frothy sputumNew S3 heart soundAdvanced hemodynamics:High wedge pressureLow cardiac indexPriority actions:Avoid aggressive fluidsReduce afterloadStart inotropes (dobutamine, milrinone)Pressors if needed (norepinephrine is first-line)Immediate cardiology intervention (cath lab, mechanical support)C. Distributive Shock — “The Leaky Pipes”Includes:SepticAnaphylacticNeurogenicAdrenal crisisEarly septic shock often looks warm:Warm, flushed skinBounding pulsesWide pulse pressureHigh cardiac output, low vascular resistanceNeurogenic shock exception:Warm, dryBradycardicCaused by spinal cord injury above T63. SIRS vs. Sepsis-3SIRS (old criteria): too sensitive, not specific; triggered by many non-infectious conditions.Sepsis-3 definition:Life-threatening organ dysfunction caused by a dysregulated response to infection.SOFA ScoreICU tool measuring organ failure across six systems.QS-SOFA Bedside ScreenSuspected infection + 2 of 3:Respiratory rate 22 or higherAltered mentationSystolic pressure 100 or less→ Activate sepsis pathway immediately.4. Defining Septic ShockSepsis PLUS:Vasopressors needed to maintain a MAP of 65Lactate level over 2 despite adequate fluid resuscitation→ Mortality increases dramatically.5. Universal Nursing Actions for ShockAirway, breathing, circulation firstHigh-flow oxygenTwo large-bore IVs immediatelyGoal-directed fluidsUrine output target: 0.5–1 per hour → early marker of organ perfusionSerial lactatesFor sepsis:Blood cultures before antibiotics if no delayBroad-spectrum antibiotics within 60 minutesPressors through central line when possibleMaintain warmth; initiate stress-ulcer and DVT prevention6. 5-Minute Bedside Differentiation TriadHypovolemic: Cold + flat veinsCardiogenic: Cold + wet lungsDistributive (early septic): Hot + flushedNeurogenic: Warm + bradycardicMaster these patterns → fast, accurate recognition. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Check out www.thinklikeanurse.org1. Opioids – Respiratory DepressionRed Flag: Respiratory rate below 8–10Action: Stop the infusion immediately, administer naloxone, monitor closely for re-sedation.2. Heparin – HIT (Heparin-Induced Thrombocytopenia)Red Flag: Platelets below 100,000Action: Stop heparin immediately, notify provider, avoid antiplatelets.3. Warfarin – Excessive AnticoagulationRed Flag: INR above 3.5–4 or any active bleedingAction: Hold the dose, give vitamin K (planned) or FFP (active bleed).4. Digoxin – ToxicityRed Flag: Yellow/green halos, heart rate below 60, significant nauseaAction: Hold digoxin, draw serum level before considering antidote.5. Potassium Chloride – IV DangerRed Flag: Severe burning, rhythm changes, undiluted infusionAction: Stop the infusion instantly.6. Vancomycin – Red Man SyndromeRed Flag: Intense flushing and rash during infusionAction: Slow the infusion, pre-treat with diphenhydramine for future doses.7. Phenytoin – Purple Glove SyndromeRed Flag: Purple, swollen, painful IV siteAction: Stop the infusion, use slow rate and inline filter for prevention.8. ACE Inhibitors – AngioedemaRed Flag: Rapid swelling of lips, tongue, or faceAction: Stop the drug immediately, never restart ACE inhibitors.9. Aminoglycosides – OtotoxicityRed Flag: New tinnitus or hearing lossAction: Stop the medication, check peak and trough levels.10. Lithium – Toxicity From DehydrationRed Flag: Coarse tremor, confusion, severe nauseaAction: Hold the dose, check level, increase fluids.11. Serotonin Syndrome – SSRI/SNRI EmergencyRed Flag: High fever, agitation, rigidity, hyperreflexiaAction: Stop the medication immediately, initiate cooling and supportive care.12. NSAIDs/Aspirin in Children – Reye SyndromeRed Flag: Child with viral illness taking NSAIDs/aspirinAction: Stop immediately, switch to acetaminophen.13. Metformin – Contrast Dye Risk / Lactic AcidosisRed Flag: Upcoming contrast study or muscle pain/drowsinessAction: Hold 48 hours before and after contrast.14. Magnesium Sulfate – OB ToxicityRed Flags: Respiratory rate below 12, absent DTRs, low urine outputAction: Stop magnesium, give calcium.15. Beta Blockers – BradycardiaRed Flag: Heart rate below 50–60 with symptomsAction: Hold dose, notify provider; glucagon for severe overdose.16. Antiplatelets (Clopidogrel/Ticagrelor) – Surgical BleedingRed Flag: Scheduled surgery within 3–5 daysAction: Hold medication pre-op (5 days for clopidogrel, 3–5 for ticagrelor).17. Amiodarone – Pulmonary ToxicityRed Flag: Persistent dry cough, new shortness of breath, abnormal chest imageAction: Stop amiodarone, start steroids.18. Chemotherapy Vesicants – ExtravasationRed Flag: Burning, swelling, pain at IV siteAction:Stop the infusionDo NOT remove the IVAspirate the drugRemove needleApply cold (or heat for vinca alkaloids)Give antidote Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Visit thinklikeanurse.orgEPISODE NOTES1. Why Pharmacology Is the GatekeeperLargest and most feared NCLEX subsection.Students may face 20–50+ pharm questions in a row.Scoring under 58% on pharm practice drops first-time pass chance to ~30%.NCLEX repeatedly tests the same 15–20 high-danger scenarios, not broad memorization.2. The Strategy Shift: From Memorizing Everything → Knowing the Life-Threatening Red FlagsStop memorizing hundreds of drugs.Master the 60–70 prototypes (“Dirty 60”) and the red-flag dangers they carry.NCLEX focuses on:Immediate safety threatsPriority nursing actionsReversal agentsToxicity signsSafe administration rules3. The High-Yield Antidotes (Guaranteed Questions)You will see 1–3 antidote questions on the NCLEX.High-Alert DrugAntidoteHeparinProtamine sulfateWarfarinVitamin K; FFP if actively bleedingOpioidsNaloxoneBenzodiazepinesFlumazenilAcetaminophenAcetylcysteineDigoxinDigiBindMagnesium sulfate toxicityCalcium gluconateBeta-blocker overdoseGlucagon4. The “Dirty 60” Prototype DrugsPain / AnticoagulantsOpioids: morphine, hydromorphone, fentanylAnticoagulants: heparin, enoxaparin, warfarin, one DOAC (apixaban)Endocrine / DiabetesInsulins: regular, NPH, lispro, glargineMetforminCardiac / Rhythm / BP ControlDigoxinAmiodaroneAdenosineDopamineNitroglycerinMetoprololACE inhibitors (lisinopril, enalapril)ARBs (losartan)HydralazineNeurologicalPhenytoinValproic acidLevetiracetamMagnesium sulfate (OB + seizure)AntibioticsVancomycinGentamicinTobramycinCeftriaxonePsychLithiumMajor antipsychoticsMiscellaneousAcetaminophenPotassium chlorideAlbuterolLevothyroxine5. The Most Common NCLEX Red-Flag Scenarios & Priority ActionsOpioids → Respiratory Rate Below 8–10Action:Stop infusion immediatelyGive naloxoneStay with patientHeparin → HIT (Heparin-Induced Thrombocytopenia)Red flag: platelets <100,000Action:Stop heparinLabel as allergicNotify providerNever give aspirinACE Inhibitors → AngioedemaAirway emergencyAction:Stop ACE inhibitor for lifeNever restart any drug in the classVancomycin → Red Man SyndromeFlushing during infusionAction:Slow rate to 90–120 minutesPre-treat with antihistamineNot a true allergyAminoglycosides → OtotoxicityRinging, hearing lossAction:Stop drugNotify providerCheck peak/trough levelsDigoxin ToxicityRed flags:Yellow/green halosHR <60Severe N/VAction: Holds dose, check dig level, notify providerMetformin Danger SituationsRed flags:Any imaging with IV contrastMuscle pain + drowsiness → lactic acidosisAction:Hold 48 hours before & after contrastMonitor kidneysMagnesium Toxicity (OB)Red flags:Respiratory depressionLoss of reflexesAction:Give calcium gluconate6. Calculations & IV Rules (Deadly NCLEX Traps)Two formulas you must know:Dose calculations:Desired ÷ Have × VehicleIV drip rate:Total Volume ÷ Time in minutes × Drop factor50 calculation problems daily builds automaticity.7. IV Push Safety Rules the NCLEX LovesNever IV push undiluted potassium chloride (instant cardiac arrest)Fentanyl/morphine: push over 4–5 minutesAdenosine: must be pushed in 6 seconds, followed by rapid flushBlood transfusion:Two nurses verifyStay with patient for first 15 minutes8. The 8-Week Pharmacology Mastery PlanWeeks 1–2: Content OnlyMemorize Dirty 60Memorize antidote listUse Anki/QuizletNo practice questions yetWeeks 3–4: Math Weeks50 dosage calcs per dayBuild accuracy + speedWeeks 5–6: Question Immersion100 pharm questions per dayRead every rationaleWeek 7: ConsolidationWatch Simple Nursing, Mark KlimekOnly focus on high-yield drug classesWeek 8: Final PrepMixed blocksTrack pharm separatelyGoal: 65%+ (UWorld 70–80%)Three cheat sheets to print:Dirty 60Antidote chartIV push rates + insulin peaks9. Final Thought: Lithium ToxicityWhy push fluids?Because lithium is excreted entirely through the kidneys.Hydration increases clearance and prevents worsening toxicity. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Check out thinklikeanurse.orgComprehensive Episode NotesI. The “Critical Triangle” for NCLEXFluids, electrolytes, and acid–base interpretation form the foundation of the NCLEX physiological adaptation category.Accounts for ~11–17% of exam questions.Mastery requires recognizing patterns, sequences, and priorities.II. Fluid Volume: Absolute Loss vs DehydrationA. Absolute Volume LossFluid physically leaves the vascular space.Causes: trauma bleeding, burn plasma loss, third spacing.Third spacing = fluid shifts out of vessels into unusable spaces (e.g., pancreatitis abdomen).Treatment: volume replacement.B. Pure DehydrationLoss of free water > sodium.Hallmark: high sodium (hypernatremia).Seen in elderly, confused, poor intake.Treatment: free water replacement, not saline.III. Burn Management & The Parkland FormulaEquation: 4 mL × weight × % TBSA burns (2nd & 3rd degree).Half must be given in the first 8 hours (critical due to peak capillary leak).Preferred fluid: LR (unless potassium is high).LR contraindicated in crush injuries or pre-existing hyperkalemia → switch to normal saline.Large volumes of normal saline risk hyperchloremic metabolic acidosis.IV. Fluid Overload: Early vs Late SignsEarlyBounding pulses.Widened pulse pressure.LateCrackles.JVD.Dyspnea.Early detection prevents progression to pulmonary edema or cardiogenic complications.V. Hemodynamics & Shock DifferentiationA. Hypovolemic vs Cardiogenic ShockBoth show:Low cardiac output.High SVR.Difference:Filling pressures low in hypovolemia (tank is empty).Filling pressures high in cardiogenic (pump fails; backup into lungs).B. Early Warm Septic ShockBreaks the usual rules:Low SVR from vasodilation.High cardiac output as compensation.High mixed venous oxygen (SVO2) because tissues cannot extract oxygen.Profile: High CO + Low SVR + High SVO2 = Early sepsis.VI. Potassium: The Most Lethal ElectrolyteEmergency sequence (memorize the order):Protect the heart: IV calcium gluconate.Shift potassium into cells: Regular insulin + D50, or high-dose albuterol.Remove potassium: Binders or dialysis.Critical pearlIf potassium won’t correct → check magnesium first.Low magnesium prevents potassium retention.VII. Sodium: Emergencies & Rate of CorrectionA. Low SodiumAcute symptomatic (seizing): give 3% hypertonic saline quickly.Chronic low sodium: NEVER increase more than 8–12 per 24 hours.Risk: osmotic demyelination syndrome (ODS).B. High SodiumReplace free water slowly.Do not correct faster than ½ per hour.Risk: cerebral edema.VIII. Calcium & MagnesiumLow calcium causes neuromuscular irritability:Chvostek’s sign.Trousseau’s sign.QT prolongation.Give IV calcium gluconate slowly (10–20 minutes) to prevent bradycardia.IX. Acid–Base Interpretation (NCLEX Method)Step-by-step sequencepH (acidosis, alkalosis, or compensated).CO₂ = respiratory component (moves opposite pH).Bicarbonate = metabolic component (moves with pH).Apply ROME mnemonic:Respiratory = Opposite.Metabolic = Equal.X. Metabolic AcidosisA. Normal Gap AcidosisCauses = HARD P S (focus on):D – Diarrhea (loss of bicarbonate).S – Saline overload → hyperchloremic acidosis.B. High Gap Acidosis (MUDPILES)Focus on:D – DKA (ketone acids).L – Lactic acidosis (shock, sepsis).XI. Metabolic AlkalosisMnemonic CLU → focus on U = Upper GI losses.Vomiting, NG suction = loss of hydrochloric acid.Treatment requires:Normal saline (volume).Chloride (to exchange for bicarbonate).XII. Compensation: Winter’s FormulaExpected CO₂ ≈ 1.5 × bicarbonate + 8 (±2).Use to detect mixed disorders.Example:If expected CO₂ is 21–25 but actual is 15 → metabolic acidosis with respiratory alkalosis.XIII. Priority Actions (ABCs First)Stabilize airway/breathing before calling the provider.Emergency actions:Anaphylaxis → epinephrine IM.Tension pneumothorax → immediate needle decompression.Post-op day 2–3 SOB → assume pulmonary embolism.Red man syndrome → stop infusion, antihistamine, restart slowly.HIT → stop heparin, switch to direct thrombin inhibitor.XIV. DKA & PotassiumHigh or normal potassium on arrival is misleading.Total body potassium is low.As soon as insulin is given → potassium drops fast.Anticipate and replace aggressively.XV. Mixed Disorder Example: Aspirin ToxicityStimulates respiratory center → respiratory alkalosis.Produces organic acids → high gap metabolic acidosis.Check out thinklikeanurse.org Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Check out thinklikeanurse.orgNotes: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 BrookeWallaceRN@gmail.com

Notes:Check out thinklikeanurse.org to get more out on this!The Ten Rights of Medication Administration:Includes the original five (patient, drug, dose, route, time), expanded to emphasize the critical thinking required by right documentation, right education, and patient’s right to refuse.Independent double checks for high-alert drugs (insulin, opioids, anticoagulants, concentrated potassium chloride).Critical point: Documentation must include the patient’s response, particularly within the hour for PRN medications.Side Effects vs. Adverse Effects:Side effects are predictable, like mild nausea or dry mouth.Adverse effects are potentially harmful reactions.Red Man Syndrome (vancomycin) vs. true allergy: Red Man Syndrome is not an allergy, but a histamine release due to rapid infusion. The solution is to slow the infusion over two hours, not stop the drug.High-Risk Drug Interactions:Warfarin and vitamin K-rich foods (like kale, spinach) neutralize the drug's effects.Grapefruit juice can interfere with the metabolism of several medications, leading to toxicity.Serotonin syndrome from combining SSRIs with MAOIs or Tramadol can lead to fever, confusion, and muscle rigidity.Medication Math:Key tip: Always use dimensional analysis and confirm that the units in the IV bag match the order.Pediatric dosing error: forgetting to convert milligrams to micrograms can cause a 1,000-fold dosing error.Subcutaneous Injections:Insulin: Pinch the skin, inject at a 90° angle, and do not aspirate.Enoxaparin (Lovenox): Inject into the abdomen 2 inches from the belly button, never massage (to prevent bruising/hematomas).Heparin can be massaged (depending on hospital policy).Intramuscular Injections (IM):Ventrogluteal site is safest.Deltoid: Only for small volumes (vaccines).Vastus lateralis: Preferred in infants.IV Push Medications:Must know dilution requirements and the safe infusion rate to avoid critical errors.Critical Medication Prototypes:Insulin (NPH, rapid-acting): Hypoglycemia is most common in the first two hours after injection for rapid insulins.Regular insulin is the only type that can be given IV in emergencies like DKA or hyperkalemia.Digoxin: Toxicity risk is higher if potassium is low.Pain Management:Opioids cause sedation, respiratory depression, and constipation.Naloxone (opioid reversal agent) must be administered slowly to avoid precipitating severe pain and withdrawal.Meperidine (Demerol) is contraindicated in patients with kidney disease due to risk of seizures.Central Venous Access Devices (CVADs):Huber needle must be used for implanted ports to avoid damaging the port's septum.Air embolism prevention requires Trendelenburg position and Valsalva maneuver.Parenteral Therapies:Hypertonic saline (3%) must be given via a central line to prevent vein damage.Infiltration and extravasation require different management strategies; extravasation is an emergency.TPN (Total Parenteral Nutrition) requires a central line and a micron filter to catch precipitates.If TPN runs dry, D10W or D20W should be given at the same rate to prevent hypoglycemia.Blood and Blood Products Administration:Two-person verification of patient identity, blood type, and expiration date is required.Platelets must be stored at room temperature with constant agitation to avoid clumping.If a severe hemolytic reaction occurs, STOP the transfusion immediately and notify the physician. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

I. Assistive Devices & Mobility CanesHandle height: aligns with greater trochanter.Elbow slightly flexed (15–30 degrees).Too high → shrugging; too low → stooping → fall risk.WalkersHeight at wrist crease with arms relaxed.Promotes upright posture and stability.Crutches (major safety trap)Two to three finger widths between axilla and crutch pad.Weight on hands only, never in armpits (brachial plexus injury risk).Stairs mnemonic: Up with the good, down with the bad.Up: good leg → crutches + bad leg.Down: crutches + bad leg → good leg.MRI PrecautionsRemove hearing aids (metal components heat or pull).Verify prosthetics for compatibility.Prosthetic Limb CareDaily skin checks.Liner must be smooth to prevent pressure injuries.II. Immobility & Skin IntegrityTissue injury develops in as little as 2 hours of unrelieved pressure.#1 priority for bedbound patient: reposition every 2 hours (more vital than specialty mattress).Tools:Trochanter roll → prevents external rotation.Footboard → prevents foot drop.Trapeze bar → increases independence and reduces shear.Compression Devices (SCDs/TEDs)Remove each shift for skin checks.Contraindicated in arterial insufficiency (risk of ischemia, gangrene).Safety First ScenarioBedbound patient trying to get up: activate bed alarm and lower bed before anything else.III. Comfort Measures (Non-Pharmacologic)Cold therapy: avoid in Raynaud’s (vasoconstriction).Heat: avoid on acute injuries or areas without sensation.Distraction vs. guided imagery:Distraction = short, procedural pain.Guided imagery = chronic or long-duration pain.IV. End-of-Life & Hospice CareTerminal secretions (“death rattle”)Appropriate: reposition, elevate head, possible scopolamine.Avoid: deep suctioning (causes distress, minimal benefit).Family concern: “Morphine will hasten death.”Explain the principle of double effect: medication is used solely for comfort, not to shorten life.Post-mortem prioritiesSupport family first.Prepare body: dentures in, eyes closed, clean gown, tidy room.Remove jewelry unless family requests otherwise (document carefully).V. Nutrition & Aspiration PreventionAspiration RiskRed flag: coughing after thin liquids.Progression: nectar → honey → pudding thick.Chin tuck recommended for safe swallowing.Tube FeedingHigh gastric residual (ex: above 350): stop feeding and notify provider.Hydration AssessmentMost accurate: daily weights.One kilogram change equals one liter of fluid.VI. Elimination & Device SafetyOstomy TeachingHigher in the GI tract = more liquid output (ileostomy).Lower in the GI tract = more formed stool (sigmoid).Catheter Balloon SafetyInflate only with the exact printed volume.Overfilling → balloon rupture or trauma.VII. Hygiene, VAP Prevention, & ICU CareVentilated patients require chlorhexidine oral care every 2 hours.Includes brushing, suctioning, and mouth care bundle steps.VIII. Delegation & Critical ThinkingUAP can reposition, but nurse must assess skin.Understanding basic care enables correct prioritization and safe delegation.IX. Complementary & Alternative Therapies (CAM)Patient taking ginkgo biloba before surgery → MUST notify surgeon due to bleeding risk.X. Final Clinical PrincipleSleep hygiene & clustering care dramatically improve recovery.Basic care supports physiological healing in every system. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Psychosocial Integrity for NCLEX: Abuse, Suicide Risk, and Therapeutic Communication00:00 – Welcome to Think Like a NurseHost intro: Brooke Wallace – ICU nurse, organ transplant coordinator, clinical instructor, published authorMission: Make complex nursing topics easier to understand, absorb, and applyWhy psychosocial integrity matters: only ~6–12% of the licensing exam, but extremely high-stakesFocus: safety, ethics, crisis management, communication, culture, cognition, and end-of-life careAbuse and Neglect: Report Suspicion, Not ProofMandatory reporting laws: the key rule → “Report suspicion, not proof.”The nurse is not a detective; the duty starts at reasonable suspicionBiggest mistake: waiting, “investigating,” or hoping it doesn’t happen againRed flags: unexplained bruises, stories that don’t match, fearful or withdrawn client, possible traffickingClassic NCLEX-style scenario:Child with spiral fracture, twisting mechanism, terrified of parent → immediate reportManaging Aggression and Restraints: Least to Most RestrictiveBehavioral hierarchy: always least restrictive to most restrictiveStart with: verbal de-escalation, limit setting, behavioral contracts, CPI techniquesWhen restraints are used:Only for immediate safetyOne-to-one observation requiredSafety checks every 15 minutes (skin, circulation, comfort)Provider order within 1 hourRN responsibilities vs. UAP:RN: assess, decide on restraints, re-evaluate needUAP: may be delegated to sit one-to-one and perform 15-minute safety checks per policySubstance Use: Alcohol Withdrawal vs. Opioid WithdrawalHigh-risk withdrawals: alcohol vs. opioidsAlcohol withdrawal (especially DTs) → can be fatalPatho: loss of GABA “brakes” → CNS hyperdrive, seizures, autonomic instabilityOpioid withdrawal → miserable but rarely fatalNausea, vomiting, pain, anxietyPriority sequence in suspected alcohol withdrawal:Give thiamine and glucose first to prevent Wernicke–KorsakoffThen treat withdrawal with benzodiazepinesTools mentioned: CIWA for alcohol, COWS for opioidsNCLEX scenario: client with DTs seeing bugs/spiders on the wall → safety + benzosSuicide Risk and Crisis InterventionRule #1: Suicide risk is always the priorityCrisis basics: usually time-limited (~6–8 weeks) → aim is return to pre-crisis functioningSteps: assess lethality and safety → stabilize → support understanding → build coping alternativesSuicide precautions: one-to-one observation, remove sharps, no cords/belts, environment safety checkThese interventions protect both the patient and your licenseCoping Mechanisms, Defense Mechanisms, and CommunicationAdaptive vs. maladaptive copingCommon defense mechanisms: denial, regression, projection, displacement, rationalizationExample:Patient says “I’m fine” after a devastating diagnosis → denialPatient insists “All the nurses hate me, they’re trying to mess up my recovery” → projectionTherapeutic response:Do not argue with content or delusionName and validate the feeling underneath:“It sounds like you feel like people are working against you right now.”Cultural Humility and Spiritual Care (LEARN + FICA)LEARN model:L – Listen to the client’s perspectiveE – Explain your perceptionA – Acknowledge differences and similaritiesR – Recommend treatmentN – Negotiate a plan togetherKey cultural examples:Jehovah’s Witness → refusal of blood productsSome Hispanic families → strong family involvement in decisionsMuslim clients → modesty, gender concordance if possibleHerbal tea/folk remedies: assess safety and interactions, don’t reflexively say noFICA framework for spiritual assessment: Faith, Importance, Community, Address in careTherapeutic Communication: The Most Tested SkillGoal: build trust and keep the focus on the client’s emotionsWhat works:Broad openings (“Tell me more about…”)Reflection, paraphrasing, clarifyingOpen-ended questionsFeeling-focused statementsExample after miscarriage:Avoid: “It’ll be okay.”Use: “This is so painful. Tell me what you’re feeling right now.”What to avoid (communication blocks):False reassurance (“Don’t worry, everything will be fine.”)Giving adviceChanging the subject“Why” questions (makes clients defensive)58:00 – Cognition, Validation, and End-of-Life CareDistinguishing:Delirium – acute, fluctuating, often reversible, worsens at night (sundowning)Dementia – chronic, progressive declineDepression – may mimic dementia (pseudodementia), associated with SIG E CAPS–type symptomsAlzheimer’s example:“I want to go home.” → use validation (“It sounds like you miss home. Tell me about it.”)Reserve reorientation for acute deliriumHospice vs. palliative care:Hospice: comfort care with limited prognosis, no curative treatmentPalliative: symptom management and quality of life, can occur alongside curative careKubler–Ross stages: denial, anger, bargaining, depression, acceptancePhysical signs of impending death: mottling, cool extremities, breathing pattern changesFamily questions about “how long”: focus on listening, fear, and comfort rather than specific timelinesNormal vs. complicated grief: function vs. long-term inability to function (e.g., widowed person still unable to leave home after years)High-Yield Psychosocial Recap (Top 5 Takeaways)Therapeutic communication is key – focus on feelings, open-ended questions, no false reassurance.Abuse and neglect – report on suspicion, don’t wait, don’t investigate independently.Suicide risk is always priority number one – one-to-one observation and environmental safety.Alcohol withdrawal can kill – give thiamine and glucose first, then treat with benzodiazepines.Cultural humility – use frameworks like LEARN to negotiate a care plan that respects the patient’s values and beliefs. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

1. Safety Culture: From Blame to LearningNon-punitive reporting → encourages learning from near-misses.Focus on system improvement, not punishment.Incident reports:Internal risk-management tools—never document “incident report filed” in the chart.Chart only objective facts and nursing actions.2. Fall Prevention: Mnemonic FALLSF – Floors clear and dryA – Ambulation aids within reachL – Lighting bright, especially to bathroomL – Low bed positionS – Shoes/non-skid socksTop priorities: Bed low, non-skid shoes, call light accessible, frequent rounding.3. Pressure InjuriesBraden Scale ≤ 18 = High risk.Reposition every 2 hours, offload heels completely.Use pressure-relief surfaces.4. EmergenciesCode Blue: Call for help, start CPR—CAB sequence.Rapid Response: Activate team, stay with patient, reassess continuously.Code Stroke: Time = brain. Prepare for stat CT, frequent neuro checks q15 min.5. Fire SafetyRACE: Rescue → Alarm → Confine → Extinguish.PASS: Pull pin → Aim low → Squeeze → Sweep.6. Hazardous MaterialsChemo: Double gloves, chemo gown, black chemo-waste container.Radioactive Implants: Time, Distance, Shielding; restrict visitors < 30 min; lead containers for waste.7. Ergonomics / Zero-Lift MethodBend knees, keep load close, push > pull.Use hoists/slide sheets if > 50% assist needed.8. Infection ControlStandard Precautions: Apply to every patient; hand hygiene before/after contact.Airborne: N95 mask + negative pressure room (TB, measles, chickenpox).Mnemonic: My Chicken Has TB.Contact: Gown + gloves (MRSA, VRE, C diff).C diff: Soap and water only—no alcohol sanitizer.PPE Donning: Gown → Mask/Respirator → Goggles/Shield → Gloves.PPE Doffing: Gloves → Goggles/Shield → Gown → Mask (outside room) → Hand hygiene.9. RestraintsLast resort—never PRN.Violent: Order valid 4 hrs, check q15 min.Non-violent: Order valid 24 hrs, check q15–30 min.Remove q2h for skin check, ROM, fluids, toileting.Use quick-release knots only.10. Security & Home SafetyInfant abduction: Matching ID bands + security tags.Elopement: Wanderguard bracelets, room away from exit.Home safety: Remove throw rugs, add grab bars & lighting.Crib safety: No soft bedding, slats < 2⅜ in apart.Hot water heater: < 120°F to prevent burns.Critical Thinking Made SimpleWhen things go wrong, think system, not individual.Was staffing safe? Was the environment optimized? Reporting and analyzing these issues strengthens safety culture.Quick RecapSafety culture > blame cultureIncident report = risk management toolFALLS & RACE/PASS mnemonicsAirborne vs Contact precautions (PPE sequences)C diff → soap and waterRestraint rules and time limitsHome safety teaching pointsNCLEX Practice QuestionA patient with C diff requires wound care. Which PPE combination is correct?A) Gloves onlyB) Gown + GlovesC) Mask onlyD) Gown + Mask✅ Answer: B.Rationale: Contact precautions require gown and gloves. Use soap and water after care. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Episode Notes: Prioritizing Critical Nursing Care & Assessment1. Normal Aging: What Is ExpectedLess subcutaneous fatPresbycusis (age-related high-frequency hearing loss)Reduced vital capacity → gets breathless more easilySlower gait, unsteady movementSlower cognitive processingMild recent-memory declineKey nursing actions:Monitor intake and outputBe cautious with medications cleared by kidneysGive simple, step-by-step instructionsAssess social support and isolation riskEN-klex trap:“Increased gait speed” = NOT normal aging“Intact recent memory” in older adults = distractor2. Immediate Safety First: Environmental Fixes Before Anything ElseScenario: Older adult climbing over raised bed railsFirst action: Lower the entire bedWhy:Fastest way to prevent injuryEnvironmental change beats calling for help or medsRestraints require an order and take time3. Maslow Priority: Physical Beats Psychosocial Every TimeScenario: Client is sad and lonely but blood pressure is extremely highFirst priority: Address the physical threat → recheck BP for accuracyReason: Physical instability always beats emotional distress.4. Postpartum Priority Sequence (Non-Negotiable Order)Check the fundus — must be firm, midlineAssess lochia — evaluate bleedingPain medicationAmbulationWhy: Hemorrhage is the most preventable cause of postpartum death.Bleeding always comes before pain.Fundus expectations immediately after birth:Firm (grapefruit-like)MidlineAt the level of the umbilicusDrops one finger-width per day5. Pediatric Development MilestonesErikson Examples:Toddler: Autonomy vs. shame → “NO” stageMiddle adult: Generativity vs. stagnationLanguage milestones:12 months: 1–3 specific words (“mama,” “dada”)15 months: Same range still acceptablePreschool thinking:Imaginary friends = normalCentration = focuses on one aspect onlySquare copying and fully clear speech → later stagesMoro reflex:Should disappear by 3–4 monthsPersistence → neurological red flag6. Prevention Levels (Know These Cold)Primary: Prevents disease (vaccines)Secondary: Early detection (mammograms, colonoscopy, screening CT)Tertiary: Manage complications (rehab, chronic care)TDap pregnancy timing:Give between 27–36 weeks for passive newborn protectionLung cancer screening:Ages 50–80Twenty pack-year historyCurrent smoker OR quit within last 15 yearsAnnual low-dose CT7. Physical Assessment RulesAbdomen (Strict Order):InspectListenPercussPalpateReason: Touching stimulates bowels → false readings.Breath sounds:Vesicular = heard best in lung peripheryBlood pressure cuff sizing:Bladder should cover 80% of upper arm circumferenceToo small → falsely highToo large → falsely lowCapillary refill:Slow if:ColdDehydratedPoor circulationNot usually slowed by high blood pressure.8. Delegation: What the UAP Can DoUAP CAN:Basic hygieneMealsAmbulation assistanceNewborn bathUAP CANNOT:Fundal assessmentLochia assessmentAny evaluationAny teachingAnything requiring clinical judgmentRN always keeps assessment, evaluation, and teaching.9. Orem’s Self-Care TheoryScenario: Client has the skills + knowledge to change a colostomy bag but refuses to look at the stoma.Deficit: Motivation deficit → needs emotional support, not more teaching.10. Priority Themes Throughout the EpisodeSafety before comfortEnvironment adjustments before interventionsPhysical danger beats psychosocial needsBleeding beats painAssessment before actionRationale behind every stepThink like a nurse, not a task robot Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Health Promotion & Maintenance (HPM) OverviewCovers lifespan: preconception → newborn → pediatrics → adults → geriatrics.Nurse’s role: proactive teaching, risk reduction, assessing needs, prevention, and early recognition of red-flag assessment findings.Four Levels of PreventionPrimordial PreventionPrevents risk factors from ever emerging.Examples: community exercise programs, safe walking areas, school nutrition standards.Primary PreventionPrevents disease or injury before it occurs.Examples: immunizations, seat belt teaching, smoking counseling, surgery pre-teaching.Secondary PreventionDetects disease early in asymptomatic clients.Screenings: colonoscopy, pap tests, mammograms, blood pressure checks.Tertiary PreventionDisease already exists — goal is to reduce complications and maximize functioning.Examples: cardiac rehab, diabetes foot care teaching, chronic medication management.Physical Assessment — FoundationNormal sequence: Inspection → Palpation → Percussion → ListeningAbdomen exception: Inspection → Listening → Percussion → PalpationWhy? Touching first can artificially change bowel sounds.Critical Red-Flag Assessment FindingsRespiratoryStridorHigh-pitched, harsh, inspiratory sound → airway emergency.Immediate actions: call rapid response, prepare advanced airway, oxygen, suction.Tracheal deviation + absent breath sounds on one sideStrongly suggests tension pneumothorax.Prepare for needle decompression or chest tube.AbdominalHigh-pitched “tinkling” sounds → sudden silencePossible obstruction or ileus → perforation risk.Actions: notify provider, strict I/O, make NPO, prepare NG tube, assess for rebound tenderness.Key Screening TimelinesColorectal screening: Begins at age 45 for average risk.Pap tests:Age 21–29: every 3 years.Age 30–65: Pap every 3 years OR Pap + HPV every 5 years.Developmental Teaching (Erikson & Piaget)EriksonOlder adult: integrity vs. despair → use reminiscence, life review, validation.PiagetToddlers/young children: concrete, literal → simple language, medical play.Teens: abstract thinkers → risk discussions, long-term consequences.Maternal & Newborn HPMPregnancy ImmunizationsTdap every pregnancy, regardless of prior doses.Timing: 27–36 weeks → maximizes antibody transfer to baby.No live vaccines during pregnancy (MMR, varicella).Administer postpartum; avoid pregnancy for 28 days after MMR.Postpartum Hemorrhage PrioritiesFundal massageOxytocinRapid fluidsCall for helpPrepare for additional interventions (e.g., uterotonics)Newborn HypoglycemiaSigns: jittery, tremors, irritability, lethargy, poor feeding.Check glucose immediately; feed or give IV glucose per protocol.Geriatric HPMCognitionMild slowing is normal. Dementia is NOT normal aging.PolypharmacyUse Beers Criteria to identify unsafe medications.High risk meds: sedatives, benzodiazepines, anticholinergics.Fall PreventionFix environment first: lighting, footwear, remove rugs, grab bars.Screening Mnemonic: ABCDA: A1CB: Blood pressureC: Colon cancerD: DEXA (bone density)Behavior Change TeachingMotivational Interviewing: OARSO: Open-ended questionsA: AffirmationsR: Reflective listeningS: SummariesTobacco Cessation: Five A’sAssessAdviseAgreeAssistArrangeEthical Note on GeneticsClients with positive BRCA results are not obligated to inform family members.Respect autonomy and confidentiality. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

This episode, created by Brooke Wallace, dives deep into one of the most tested and essential areas for nursing students—Safety and Infection Control (10–16% of the NCLEX). Listeners learn how to apply a “safety culture” mindset, document correctly, prevent injury, respond to emergencies, and follow infection control principles that protect both patients and staff.1. Safety Culture ShiftMove from blame to non-punitive culture—errors reveal system issues, not individual failure.Encourage reporting near-misses; they identify system cracks before harm occurs.Incident reports: Document objectively, never mention in the patient’s chart (keeps it non-discoverable legally).Chart only facts and interventions (e.g., “Patient found on floor, vitals stable, neuro checks initiated”).2. Fall & Injury PreventionUse tools like Morse or Hendrich II to identify high-risk patients.Mnemonic FELLAS:Floors clear, Equipment within reach, Lighting adequate, Low bed position, Assistive devices ready, Shoes non-skid.Delegate rounding but maintain RN accountability for safety setup.3. Pressure Injury PreventionBraden Scale ≤18 = high risk.Interventions: Reposition q2h, use pressure-relief surfaces, offload heels (“float the heels”).4. Emergency ResponseCode Blue (cardiac/respiratory arrest): Call code, start CPR—CAB: Compressions, Airway, Breathing.Rapid Response: Call early; stay with patient and continue assessment.Code Stroke: Activate immediately; prep for CT scan, perform neuro checks q15min.5. Fire SafetyRACE: Rescue → Alarm → Confine → Extinguish.PASS (using extinguisher): Pull → Aim → Squeeze → Sweep.Containment is key—close doors/windows to block smoke.6. Hazardous MaterialsChemotherapy: Double gloves, chemo gown, black chemo waste container.Radioactive implants: Follow Time, Distance, Shielding. Limit exposure time, keep distance, use lead containers for waste.7. Ergonomics & Zero-Lift PolicyBend knees, not back; push rather than pull.Use mechanical lifts when the patient exceeds 50% of your weight.8. Infection ControlStandard Precautions: Hand hygiene, gloves for blood/body fluids, add mask/eye protection if splashing possible.Airborne: “My Chicken Has TB” (Measles, Chickenpox, Herpes Zoster, TB).N95 respirator, negative pressure room, surgical mask on patient for transport.Contact: MRSA, RSV, C. diff.Gown + gloves, dedicated equipment, soap and water for C. diff.PPE Sequence:Donning: Gown → Mask/N95 → Goggles → Gloves.Doffing: Gloves → Goggles → Gown → Mask (outside room if N95).9. RestraintsLast resort, never PRN.Violent/self-destructive: Order valid 4 hrs (adult). Provider eval within 1 hr.Non-violent: Order valid 24 hrs max.Check/document q15min; remove q2h for circulation, ROM, toileting, skin check.Use quick-release knot only.10. Security & Home SafetyInfant safety: Matching ID bands, alarms, never leave unattended.Elopement: WonderGuard bracelets, close observation near nurses’ station.Home safety teaching:Remove throw rugs, install grab bars.Crib: firm mattress, no pillows or bumpers, “Back to sleep.”Water heater <120°F to prevent burns.11. Core Takeaways (“Nursing Pearls”)Safety culture = systems thinking.Never chart “incident report filed.”Know RACE, PASS, PPE order, and restraint limits.For C. diff, always wash with soap and water.Advocate for system fixes, not blame.12. NCLEX Practice QuestionA nurse notes a patient slipped but was uninjured. What’s the next best action?A. File an incident reportB. Document “incident report filed” in chartC. Notify risk management onlyD. Chart “patient slipped, no injury” and notify provider✅ Answer: DRationale: Chart only objective data. Incident report is separate, internal. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

The 5 Biggest Traps That Can Cost a Nurse Their License1. Ignoring a DNR or Invalid Advance DirectiveThe Trap: Starting CPR or aggressive care despite a valid DNR — or honoring an unsigned “living will.”Why It’s Dangerous: Violating patient autonomy can legally count as battery.Avoid It: Verify validity (signatures, dates, physician order). If unsure, pause and clarify before acting.2. Delegating Beyond ScopeThe Trap: Letting a UAP or LPN handle unstable patients, assessment, or teaching.Why It’s Dangerous: The RN remains accountable for all delegated tasks.Avoid It: Only delegate predictable, routine care for stable patients.Never delegate: assessment, evaluation, teaching, or IV push meds.3. Breaching Confidentiality (HIPAA Violations)The Trap: Discussing patient details in elevators, texting info on personal phones, or sharing passwords.Why It’s Dangerous: Violations can lead to termination, fines, or board discipline.Avoid It: Keep all PHI private; use secure systems only. Never deny patients access to their own records.4. Poor Documentation After an ErrorThe Trap: Writing “incident report completed” in the chart or trying to hide a mistake.Why It’s Dangerous: The incident report is not part of the legal medical record — referencing it creates liability.Avoid It: Chart only objective facts and patient care provided. File internal reports separately for quality improvement, not punishment.5. Failing to Report or EscalateThe Trap: Not reporting abuse, communicable disease, or an impaired coworker.Why It’s Dangerous: Failure to report is a criminal offense in many states and violates the nurse’s duty to protect patients.Avoid It: Report immediately to the correct authority (CPS, infection control, or board). Do not confront suspects directly.🩺 Bonus Trap: Skipping Trend RecognitionMissing a pattern like rising heart rate + falling blood pressure → delayed recognition of shock.Avoid It: Always look for trends, not single numbers — early intervention saves lives and protects your license.🩺 Summary Notes 1. Advanced DirectivesLiving will = specifies what treatments (ventilator, dialysis, feeding tubes).Durable Power of Attorney (POA) = specifies who decides if patient can’t.Never assume spouse or child is automatic proxy — document required.Unsigned forms have no legal force. Educate family on proper process.Nursing Pearl: The POA document trumps relationship status.2. Do Not Resuscitate (DNR)Nurse must honor a valid DNR, even with family protest.Starting CPR against documented wishes = battery.If DNR validity is unclear → pause, verify, educate.Provide comfort care per patient’s wishes.3. Patient Rights & Refusal of CareCompetent adults can refuse any treatment, even life-saving.Nurse’s role: document refusal verbatim, notify provider, educate.Never coerce or persuade.4. Confidentiality & HIPAACommon breaches: talking in elevators, texting on personal phones, sharing passwords.Patients can request copies of their records within 30 days.Never deny access without legal cause.5. PrioritizationUse ABCs (Airway, Breathing, Circulation) to guide priorities.Unstable trumps stable every time.Look for patterns (rising HR + falling BP = possible shock).Act immediately—don’t wait for one “bad number.”6. DelegationUAPs: routine, predictable care for stable patients. RN retains accountability.LPNs: stable patients, routine meds, reinforce teaching.RN: initial assessment, IV push meds, unstable clients.Never delegate assessment or teaching.7. Case Management & Discharge SafetyCase manager ensures safe transitions.Example: post-hip replacement living alone = unsafe discharge → rehab.Use SBAR for structured communication (Situation, Background, Assessment, Recommendation).Refer to social services for financial or literacy barriers.Use teach-back method to verify understanding before discharge.8. Handoff & CommunicationUse iPASS (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver).Always include contingency plans (what to do if condition worsens).9. Ethical Decision-MakingRespond to suffering with empathy + professional boundaries.Offer palliative care or chaplain consult — never suggest ending life.Mandatory reporting: child/elder abuse, communicable disease, gunshot wounds, impaired coworkers → report immediately to correct authority.10. Incident Reports & Quality ImprovementNever mention “incident report” in chart.Document only facts and patient care actions.QI uses RCA (Root Cause Analysis) → identify system issues, not blame individuals.Use PDSA Cycle (Plan-Do-Study-Act) for continuous improvement.Tools: Fishbone Diagram for cause analysis.11. Informed ConsentProvider obtains consent; nurse witnesses and verifies understanding.If confusion arises → stop and notify provider before signing.12. Core TakeawayUnderstanding why these legal and ethical rules exist keeps both patients and nurses safe. It’s the foundation for safe, effective, low-stress nursing practice. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

✅ The 10 NCLEX Traps Covered in the EpisodeAssuming the spouse is the automatic decision maker→ Trap: Ignoring the legal requirement for a designated healthcare proxy.Mixing up advance directives vs. medical orders→ Trap: Treating a living will or POLST as interchangeable with a DNR.Misunderstanding informed consent roles→ Trap: Thinking the nurse provides the explanation instead of the provider.Violating HIPAA through casual conversation or curiosity→ Trap: Discussing PHI in hallways, checking charts you’re not assigned to, or posting online.Failing to use chain of command in conflict→ Trap: Not escalating when family demands contradict legal documents or patient safety is at risk.Delegating unsafely or outside scope→ Trap: Forgetting the Five Rights of Delegation or assigning unstable patients to UAPs.Incorrect prioritization under pressure→ Trap: Addressing psychosocial needs before airway, breathing, or circulation.Neglecting supervision and follow-up after delegation→ Trap: Delegating and not verifying completion or evaluating results.Skipping medication reconciliation during transitions of care→ Trap: Failing to catch duplications, omissions, or interactions during handoffs.Confusing system errors with personal blame in quality improvement→ Trap: Not recognizing that root cause analysis focuses on process—not punishment.Show Notes Summary (Key Learning Outline)Legal & Ethical FoundationsAdvance Directives: Living will, durable power of attorney, DNR/AND, and POLST.Nurse’s Role: Verify documents, educate families, advocate for patient wishes, use chain of command when in conflict.Informed Consent: Provider explains; nurse verifies understanding, witnesses signature, documents, and notifies provider if refused.HIPAA: Share minimum necessary information only; report breaches immediately.Case Management & CoordinationRN as Coordinator: Plan across the continuum—discharge planning starts at admission.Resource Utilization: Refer appropriately—social work, dietician, therapy services.Structured Communication: SBAR and teach-back methods for accuracy and safety.Medication Reconciliation: Compare meds at each transition to prevent errors.Leadership & Conflict ResolutionAssertive Communication: “I” statements, focus on safety.Chain of Command: Escalate unresolved patient-safety concerns promptly.Conflict vs. Collaboration: Maintain professionalism; document and debrief.Prioritization & DelegationPrioritization Frameworks:Level 1 = ABCs, hemorrhage, seizures.Level 2 = Acute pain, mental-status changes, safety risks.Level 3 = Routine teaching, psychosocial support.Five Rights of Delegation: Task, circumstance, person, direction, supervision.Scope Reminders:UAP: ADLs, vitals (stable only).LPN: Focused assessments, some meds, reinforce teaching—not initiate.Quality & SafetyLeadership Styles: Autocratic (emergency), democratic (team input), transformational (inspiring).Management Functions: Planning, organizing, directing, controlling (PODC).Performance Improvement: Use PDSA cycles; focus on systems, not blame.Sentinel Events & RCA: Analyze root causes; fix processes, not people.Legal AccountabilityNegligence Elements: Duty, breach, causation, damages.Mandatory Reporting: Abuse, communicable diseases, impaired coworkers.Technology Safety: Secure EHR access, barcode verification, never override alerts.💡 Key TakeawaysRNs are accountable coordinators, not just task-doers.Legal protection = follow chain of command + document everything.Prioritize using ABCs and Maslow’s hierarchy.Delegate safely using the Five Rights.Quality improvement and leadership are part of daily practice, not optional extras. Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Episode NotesKey Concepts & TakeawaysHypertensive Crisis TypesUrgent: BP >180/120 without organ damage.Oral meds (Clonidine, Captopril).Gradual BP reduction over 24–48 hrs.Watch for rebound hypertension (Clonidine) and angioedema (Captopril).Emergent: BP >180/120 with organ damage.IV meds (Labetalol, Nicardipine, Nitroprusside).ICU monitoring and titration within minutes–hours.Watch for bronchospasm (Labetalol) and cyanide toxicity (Nitroprusside).Aortic Dissection Sequence RuleBeta blocker first (Esmolol) to slow HR to ~60 before adding vasodilator.Giving vasodilator first can trigger reflex tachycardia → aortic rupture.Target BP: 100–120 systolic.Anticoagulation & Clot PreventionValvular disease (e.g., mitral stenosis + AFib): Warfarin or DOACs (rivaroxaban, apixaban, dabigatran).Monitoring: PT/INR for Warfarin, none for DOACs.Endocarditis prophylaxis: Amoxicillin pre-dental procedure; Clindamycin or Azithromycin if allergic.Pulmonary EmbolismStable: Start anticoagulation immediately (Heparin or LMWH).Unstable (shock): Thrombolysis with Alteplase (TPA).Contraindications: recent stroke, surgery, trauma, active bleeding, severe hypertension.Pediatric Cardiac PharmProstaglandin E1 (Alprostadil): Keeps PDA open; monitor for apnea, hypotension.Digoxin Safety: Hold if HR <90–110 in infants (toxicity risk).Rapid-Fire NCLEX ScenariosNitroprusside toxicity: Stop infusion immediately → give sodium thiosulfate.INR 5.5 on Warfarin: Hold dose → give Vitamin K.Aspirin allergy in ACS: Substitute Clopidogrel. Nursing PearlsOrgan damage = emergency = IV meds.Always beta-block first in aortic dissection.Stop the drip first in cyanide toxicity.Hold digoxin in infants <90–110 HR.Never give thrombolytics with recent head injury or surgery.NCLEX Practice QuestionA patient with an aortic dissection is started on IV nitroprusside before receiving a beta blocker. What is the nurse’s priority concern?A. Reflex tachycardia worsening the dissectionCorrect Answer: ARationale: Vasodilators lower BP rapidly but can trigger compensatory tachycardia, increasing aortic wall stress and risking rupture. Always administer a beta blocker first.Check out Thinklikeanurse.org for study guides, notes, downloads, and other cool stuff! Need to reach out? Send an email to BrookeWallaceRN@gmail.com

Systematic Approach (6 Steps):Rate – Regular: 300 Rule (300 ÷ # large boxes between R waves).Irregular: 6-Second Strip Method (R waves in 6 seconds × 10).Rhythm – Regular or irregular?P Wave – Present before every QRS?PR Interval – Normal: 0.12–0.20 sec (3–5 small boxes).If the R is far from P → first-degree block.QRS Complex –Narrow (<0.12 sec): supraventricular origin (normal pathway).Wide (>0.12 sec): ventricular origin or bundle branch block.Mnemonic: Narrow = Normal, Wide = Worry.Interpretation – Identify rhythm and appropriate intervention.Key Rhythms & Interventions:Normal Sinus Rhythm (NSR): 60–100 bpm, consistent P before QRS. → Routine monitoring.Atrial Fibrillation: Irregularly irregular, no P waves, wavy baseline. → Stroke prevention with anticoagulants (warfarin or DOACs).Ventricular Tachycardia (V-tack): Fast + wide complexes. → Check for pulse first!Pulse + stable → Amiodarone.Pulse + unstable → Cardioversion.No pulse → Defibrillate.Ventricular Fibrillation (V-fib): Total chaos. → Defibrillate immediately.Mnemonic: “V-fib = Defib.”Asystole (Flatline): No electrical activity. → CPR + Epinephrine, confirm in 2nd lead.Rule: Confirm before you code.Pulseless Electrical Activity (PEA): Electrical activity without a pulse. → CPR + Epinephrine, find reversible H’s and T’s.Third-Degree (Complete) Heart Block: P’s and QRS march independently. → Immediate pacing.Mnemonic: “If P’s and Q’s don’t agree → 3rd-degree.”Shockable vs Non-Shockable:Shockable: V-fib, Pulseless V-tack.Non-Shockable: Asystole, PEA.💡 Nursing Pearl: “If there’s chaos, shock. If it’s flat, compress.”NCLEX Tip:Always check for a pulse before paddles — treat the patient, not the monitor. Need to reach out? Send an email to BrookeWallaceRN@gmail.com