Medication safety rules for the NCLEX

Every opioid patient gets a bowel regimen ON DAY 1 — stimulant + softener combo. Don't wait for constipation.

Multimodal pain = scheduled non-opioid (acetaminophen) + non-pharm (ice, position, distraction, relaxation) + opioid only as needed. Reduces sedation/constipation.

EOL comfort = symptom-targeted interventions (reposition, anticholinergic for secretions, low-dose opioid for dyspnea) + family support. NOT aggressive suctioning + invasive measures.

At 6 months: DTaP #3, IPV #3, Hib #3, PCV13 #3, RV #3 (RV5 brand), plus first INFLUENZA dose (annual season). HepB #3 by 18 months. MMR + varicella NOT until 12 months. Mild illness without fever is NOT a contraindication. Use motivational interviewing for hesitant parents — never agree-and-skip without informed-decision documentation.

Patients on chronic opioids have tolerance — acute pain requires higher per-dose opioid PLUS scheduled multimodal (acetaminophen, NSAID if safe, ice, regional, gabapentin per orders). Monitor sedation + RR using the Pasero scale before reaching for more opioid. Goal is functional pain control, not zero pain. Never add benzo for nociceptive pain — synergistic respiratory depression.

Terminal dyspnea = low-dose morphine SC/IV. Death rattle / secretions = anticholinergic (scopolamine patch, glycopyrrolate) + lateral repositioning + gentle oropharyngeal Yankauer at most. AVOID aggressive deep suctioning + IV fluids (worsen secretions/edema). Family presence + teaching that the death rattle is typically not distressing to the patient.

Recovery is built on basic care. Sleep: cluster care, dim lights, minimize nighttime vitals if stable, move diuretic to AM. Nutrition: small frequent meals + favorites + RD if 50% intake. Elimination: scheduled bowel regimen on opioids (docusate + senna), ambulate, assess before enema. Avoid benzos in elderly (Beers list).

Initial NG placement requires X-ray before any feeding or medication. pH < 5.5 + green-yellow aspirate is a bridge check while awaiting X-ray. Auscultation (air bolus) is OUTDATED and DANGEROUS — air sounds can be heard from a lung-placed tube. Mark + document external tube length after X-ray; verify length unchanged before each subsequent use.

Pain management is layered: scheduled non-opioid (acetaminophen ± NSAID if safe) + non-pharmacologic (position, splint incision with pillow, music, distraction, breathing, heat/cold per type) + PRN opioid as needed. Mobility is therapeutic — bed rest worsens DVT, atelectasis, ileus, pain. Always reassess sedation + RR before more opioid.

Opioid: scheduled docusate + senna ± PEG ladder. SCI: scheduled bowel program (consistent). Pre-procedure: specific bowel prep protocol. Impaction with leakage = paradoxical diarrhea around obstruction — do NOT give anti-diarrheal; perform DRE + manual disimpaction + mineral oil enema per protocol. Enema position: LEFT lateral (Sims), R knee flexed.

Anaphylaxis = rapid onset + 2+ systems (skin + respiratory + CV + GI) or hypotension + trigger. FIRST: IM epinephrine 0.3-0.5 mg (1:1000) in anterolateral mid-thigh, repeat q5-15 min. Adjuncts (NOT first-line): high-flow O2 + IV fluids + H1 (diphenhydramine) + H2 (famotidine) + corticosteroid + albuterol. Refractory + beta-blocker → glucagon. Observe 4-12 hr for biphasic. Discharge: autoinjector + allergy referral + medical alert.

HyperNa + polyuria post-pituitary = DI (DDAVP). HypoNa + cancer + euvolemic = SIADH (fluid restrict, slow correction). HypoK + hypoMg + loop diuretic = waste (replace BOTH — K won't normalize without Mg). HyperK + ACE-I + K-sparing = drug-induced (stabilize → shift → excrete: Ca gluconate → insulin/D50 → Kayexalate/Lokelma/dialysis). Always correct Na ≤ 8-10 mEq/L per 24 h to avoid demyelination.

Hepatocellular (ALT > AST, both very high) = direct injury (viral, drug, ischemia). Alcoholic (AST > ALT 2:1, GGT high) = alcohol. Cholestatic (alk phos + GGT very high, direct bili up) = obstruction. INR elevation = synthetic dysfunction. Acetaminophen toxicity: NAC even at day 3 may help; consider transplant evaluation if severe.

Warfarin elective surgery: hold 5 d + bridge LMWH per surgeon. Metformin + contrast: hold day of + 48 h after (lactic acidosis risk if AKI). Chronic steroids: CONTINUE + stress-dose at induction (50-100 mg hydrocortisone). DOAC urgent surgery: andexanet alfa (apixaban/rivaroxaban) or idarucizumab (dabigatran) or 4-factor PCC. NPO timing: 8 h full / 6 h light / 4 h breast milk / 2 h clear liquids.

Severe neutropenia (ANC < 500) + fever = emergency, broad-spectrum abx within 1 h. Macrocytic anemia (MCV > 100) + alcohol/neuropathy = B12 / folate (iron WON'T fix it). Thrombocytopenia after 5-14 d heparin = HIT — STOP all heparin (including flushes), switch to argatroban / bivalirudin (paradoxical thrombosis risk). Leukocytosis + > 10% bands + fever = sepsis bundle.

AKI: Cr rise ≥ 0.3 within 48 h, OR ≥ 50% over 7 d, OR UO < 0.5 mL/kg/hr x 6 h. KDIGO stages by Cr ratio + UO. Pre-renal (volume), intrinsic (ATN — nephrotoxic, ischemic, AIN), post-renal (obstruction). Stop nephrotoxins (NSAIDs, ACE-I, aminoglycosides, vanco, contrast). Volume status drives fluid decisions. RRT indications: AEIOU (Acidosis, Electrolytes refractory, Ingestion, Overload, Uremia).

POAG: gradual painless peripheral vision loss + cupping. Topical ladder: prostaglandin analog (latanoprost qHS, eyelash + iris darkening) → beta-blocker (timolol, avoid asthma/brady) → CAI → alpha agonist. ACG EMERGENCY: sudden severe pain + halos + N/V + FIXED MID-DILATED PUPIL + IOP > 40. Treat: IV mannitol + acetazolamide + topical timolol + brimonidine + PILOCARPINE (miotic to open angle); definitive = LASER IRIDOTOMY both eyes. AVOID anticholinergics + dilating drops. Drop technique: nasolacrimal pressure × 1-2 min (reduces systemic absorption).

Otitis media (middle): post-URI + fever + bulging TM + decreased mobility → watchful wait OR amoxicillin high-dose × 10 days. Otitis externa (canal, swimmer): pain WORSE with pinna pull + canal erythema + drainage → topical antibiotic + steroid drops + keep ear DRY. Pinna pull for drops: < 3 yr DOWN + BACK; ≥ 3 yr + adult UP + BACK. Prevention OE: dry ears + no Q-tips + avoid prolonged moisture.

Anterior epistaxis (90% from Kiesselbach's): SIT UP + LEAN FORWARD (not back — aspiration) + pinch SOFT part of nose × 10-15 min continuous + ice; oxymetazoline → silver nitrate cautery → anterior pack. Posterior epistaxis (10%, sphenopalatine artery, severe in elderly + anticoagulants): STAT ENT + POSTERIOR PACK (balloon/Foley) + reverse warfarin (IV vitamin K + 4-factor PCC) + admit. Prevention: humidifier + saline spray + Vaseline cotton swab application + control HTN + careful anticoag.

Viral rhinosinusitis < 10 days = symptomatic (saline rinse, decongestant short-term, analgesia, humidify, hydrate). Bacterial criteria: ≥ 10 days no improvement OR severe onset OR DOUBLE SICKENING → amoxicillin or amox-clav × 5-10 days (doxy/levo if severe PCN allergy). Chronic > 12 wk = intranasal steroid + identify cause (allergy, polyps, structural). Orbital cellulitis (proptosis + painful eye movement + decreased vision) = EMERGENCY IV abx + ENT/ophth/ID + CT + drainage. SINUS RINSES: use DISTILLED/STERILE/BOILED water (NOT tap — Naegleria fowleri risk).

Cellulitis (dermis + SC, red warm tender, gradual): cephalexin/dicloxacillin oral or IV cefazolin/vanc; elevate + mark borders. Erysipelas (upper dermis + lymphatic, SHARP demarcation + raised bright red + butterfly face): penicillin G IV then amoxicillin PO. NF EMERGENCY: pain OUT OF PROPORTION + RAPIDLY progressing + systemic toxicity (sepsis) + crepitus + bullae + dusky + lack of antibiotic response → STAT surgical debridement (don't delay for imaging) + IV broad-spectrum (carbapenem + vanc + CLINDAMYCIN for toxin suppression) + ICU + sepsis bundle. Mortality 20-40%.

In DKA the FIRST move is isotonic fluid (0.9% NS), not insulin. Check K+ before starting insulin — if K+ < 3.3, HOLD insulin and replete K+ first (insulin drives K+ into cells). Add K+ to maintenance once it falls into 3.3–5.2. Switch to D5 ½NS when glucose reaches ~200 to prevent rapid drop and cerebral edema.

The rule of 15 (15 g oral carbs, recheck in 15 min) is for an awake, swallow-safe patient. In an obtunded patient, push IV D50. For sulfonylurea-induced hypoglycemia, a single D50 isn't enough — start a D10 infusion to bridge the long drug half-life and prevent rebound.

HHS has 8–10 L of fluid deficit and minimal ketosis. Treatment is volume-led: aggressive 0.9% NS first, then slow insulin (0.05–0.1 unit/kg/hr) only after the first liter and K+ check. Aim to drop glucose 50–75 mg/dL/hr — faster causes cerebral edema. Correct Na+ slowly (≤ 10 mEq/L per 24 h).

Order matters. Iodine given before thionamide can paradoxically increase hormone release. The sequence: (1) beta blocker for adrenergic symptoms, (2) thionamide (PTU preferred in storm) to block synthesis, (3) iodine ≥ 1 hour later to block release, (4) glucocorticoid to block T4→T3 conversion. Use acetaminophen, not aspirin (aspirin displaces T4 → worsens storm).

Catecholamine-secreting tumors flood the body with epinephrine/norepinephrine. Giving a beta blocker first leaves alpha receptors unopposed → catastrophic vasoconstriction, stroke, MI. Always alpha-block first (phentolamine, phenoxybenzamine). Then beta-block. Drop BP gradually (~25% in the first hour) — too-fast lowering causes ischemia.

HypoK < 3.5: weakness, U waves, flattened T, dig toxicity. Replace via pump max 10-20 mEq/hr IV (NEVER PUSH — fatal); replace Mg concurrently. HyperK > 5.0 ECG: peaked T → wide QRS → sine wave → asystole. Treatment ORDER: (1) CALCIUM GLUCONATE IV (stabilize membrane, doesn't lower K); (2) INSULIN + D50 + ALBUTEROL (shift); (3) KAYEXALATE/FUROSEMIDE/DIALYSIS (eliminate). STOP K-sparing meds.

DKA: type 1, glucose 250-600, ketones+, HAG acidosis, Kussmaul + fruity breath. Treatment: IV fluids + insulin 0.1 U/kg/hr + replace K (HOLD insulin if K < 3.3 until replaced) + bicarbonate ONLY if pH < 6.9 + continue insulin until AG closed (switch to D5 1/2 NS when glucose 200-250). HHS: type 2 elderly, glucose > 1000, minimal ketones, profound dehydration + AMS. Treatment: AGGRESSIVE fluids primary + slower insulin (0.05 U/kg/hr) + slow glucose drop ≤ 100 mg/dL/hr (cerebral edema risk) + K + treat trigger.

Delirium is acute (hours-days), fluctuating, with inattention + altered consciousness. Dementia is gradual (months-years), progressive, with preserved consciousness early. Delirium has reversible causes: infection, hypoxia, electrolytes, dehydration, pain, retention, constipation, medications (especially anticholinergics, benzos, opioids). NON-PHARM is first-line. Benzodiazepines WORSEN delirium except in alcohol/benzo withdrawal.

Beers Criteria identifies meds to avoid or use with caution in elderly. High-risk classes: benzodiazepines, anticholinergics (diphenhydramine, oxybutynin), NSAIDs (renal/GI), Z-drugs (zolpidem), tricyclics. Deprescribing process: identify, prioritize, gradual taper, monitor. Benzodiazepines + opioids + some BP meds need slow tapers to avoid withdrawal. Replace function (sleep, pain) with non-pharm.

Fried Frailty Phenotype: unintentional weight loss + exhaustion + weakness (grip) + slow gait + low activity (3+ = frail, 1-2 = pre-frail). Causes (often reversible): depression, malignancy, GI, endocrine, malabsorption, medication. Treatment: resistance training + protein-rich nutrition (1.0-1.2 g/kg) + vit D + treat underlying causes. Frailty IS reversible.

Non-verbal patients (advanced dementia, intubated, post-stroke) need behavioral pain scales: PAINAD, FLACC, behavioral pain scale. Look for grimacing, vocalizations, body language, consolability, breathing changes. Family knowledge of baseline is essential. Treat with multimodal (scheduled acetaminophen + non-pharm + opioid PRN starting at 25-50% lower dose). Under-dosing in elderly + non-verbal is the common bias.

1-yr mortality 20-30% without optimal care. Early surgery (24-48 h) reduces mortality + complications. Pre-op: multimodal pain (nerve block — fascia iliaca — reduces opioid + delirium), warfarin reversal (vit K + PCC, INR < 1.5), DVT/pressure prophylaxis, geriatric co-management. Early mobility post-op + rehab planning critical.

Crohn's = ANYWHERE mouth-to-anus, SKIP lesions, TRANSMURAL, fistulas, strictures. UC = CONTINUOUS, rectum start, COLON only, mucosal, bloody diarrhea + tenesmus. Treatment: 5-ASA (UC > Crohn's) + steroids for flare (taper) + biologics. Surgery curative for UC, NOT Crohn's. Watch toxic megacolon (UC) + fistula/abscess (Crohn's).

Therapeutic aPTT 1.5-2.5x baseline. HIT = >50% platelet drop on day 5-10 (+ paradoxical thrombosis). STOP ALL heparin including flushes + LMWH. Use argatroban/bivalirudin. Protamine 1 mg per 100 units in last 4 hr.

AFib INR 2-3; mechanical valve 2.5-3.5. Bactrim/FQ/amiodarone/APAP chronic raise INR; rifampin/phenytoin/St John's wort/high vit K lower INR. Minor bleed = hold + low-dose oral vit K. Major bleed = IV vit K + 4F-PCC.

Lispro WITH meal; regular 30 min BEFORE meal; NPH peaks 4-12 hr; glargine basal no peak no mix. Insulin shifts K+ INTRACELLULAR — replace K+ before giving in hypokalemia. Drip → SC overlap 1-2 hr. Independent double-check.

Monitor sedation (POSS) + RR + SpO2 (capnography in high-risk). Sedation precedes RR depression. PCA by proxy = unsafe — pt only presses. Naloxone 0.04-0.4 mg IV titrated; short half-life — repeat as needed. Multimodal analgesia.

NMB requires INTUBATION + deep sedation/analgesia (RASS deep) BEFORE starting. TOF monitor (goal 1-2/4). NEVER on awake pt. Reversal: SUGAMMADEX (rocuronium/vec) or NEOSTIGMINE + GLYCO (others); cisatracurium = time + ventilation. Naloxone is OPIOIDS only.

Therapeutic 0.5-2.0 ng/mL. Toxicity: GI + yellow halos + ECG + brady + AV block. Hypokalemia + hypomagnesemia + renal failure potentiate. Treatment: STOP + Dig Fab + CAUTIOUS K+ (Fab releases dig → may cause hyperkalemia) + pacing if brady. Hold diuretics.

VOC triggers: dehydration, infection, hypoxia, cold, stress, acidosis. Treatment: IV fluids (1.5x maintenance per protocol) + O2 to SpO2 ≥ 95 + IV opioid (scheduled/PCA, not PRN-only; sickle pain is severe + real — undertreat = pseudoaddiction) + WARM compresses + treat infection. AVOID cold (vasoconstriction worsens sickling). Watch for acute chest syndrome (chest pain + fever + hypoxia + new infiltrate). Hydroxyurea prevents future crises.

Simultaneous bleeding + clotting: ↓ platelets, ↑ PT/PTT, ↓ fibrinogen, ↑↑ D-dimer + FDPs. Triggers: sepsis, trauma, malignancy, obstetric. Treatment: TREAT UNDERLYING CAUSE + supportive — FFP for PT/PTT prolongation, cryoprecipitate for fibrinogen < 100-150, platelets for active bleeding + count < 50, RBC as needed. Heparin only in select thrombotic-predominant DIC; NOT in bleeding-predominant.

Myeloma CRAB: hyperCalcemia + Renal failure + Anemia + Bone lesions. M-spike + Bence Jones protein. HyperCa management: aggressive IV NS FIRST + calcitonin (rapid) + bisphosphonate (sustained). Furosemide ONLY when euvolemic/overloaded (not before hydration). AVOID NSAIDs + IV contrast (light chain nephropathy worsens AKI). Pain: acetaminophen + opioid + radiation for bone lesions. Infection prevention (no live vaccines).

Warfarin: INR 2-3 (mech valve 2.5-3.5). Vitamin K diet CONSISTENT (not zero). Verify ALL new meds/herbals (NSAIDs, antibiotics, amiodarone, omeprazole, St John's wort). Bleeding precautions + carry medical alert. Major bleed signs: severe headache, persistent epistaxis, melena, hematuria, large bruise. Reversal: oral vitamin K (non-urgent), PCC + IV vitamin K (urgent). Bridge with heparin for procedures.

HIT type II: > 50% platelet drop 4-14 days post heparin + paradoxical thrombosis. ACTION: STOP ALL heparin (UFH + LMWH + flushes + heparin-coated lines) + start non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux). AVOID warfarin until platelets recover (skin necrosis from rapid protein C drop). AVOID platelet transfusion (worsens thrombosis). Confirm with HIT antibody + SRA. Add allergy alert. DOAC notes: avoid in mechanical valves + pregnancy.

SLE triggers: SUN/UV exposure (#1), infection, stress, pregnancy, drugs (procainamide, hydralazine, sulfas). Hydroxychloroquine foundational (annual eye exam for retinal toxicity); never stop. Lupus nephritis (RBC casts + proteinuria + ↑Cr) = high-dose steroids + cyclophosphamide/MMF + biopsy. Steroid taper gradual (adrenal crisis if abrupt). Sun protection SPF 30+ + clothing + avoid tanning + hat.

Myasthenia gravis: AChR antibodies; weakness worsens with USE, improves with REST. Myasthenic crisis (under-treated/infection): weakness, respiratory failure, NO SLUDGE → MORE anticholinesterase + IVIG/plasmapheresis. Cholinergic crisis (overdose): SLUDGE (salivation, lacrimation, urination, defecation, GI cramps, emesis) + bradycardia + miosis → HOLD pyridostigmine + atropine. Monitor FVC + NIF. AVOID aminoglycosides + magnesium + beta-blockers + neuromuscular blockers.

Limited cutaneous systemic sclerosis = CREST (Calcinosis + Raynaud + Esophageal dysmotility + Sclerodactyly + Telangiectasias). Raynaud: keep warm + gloves + no smoking + CCB (nifedipine); AVOID beta-blockers (worsen Raynaud). Esophageal: small frequent meals + upright + PPI + HOB elevated. Skin: emollients + ulcers monitoring. Annual screen: pulmonary HTN (echo) + ILD (CT/PFT). Scleroderma renal crisis (new HTN + AKI) → ACEi STAT (life-saving exception).

Allergy assessment: distinguish IgE-mediated (anaphylaxis, urticaria minutes) vs side effect vs delayed rash vs severe (SJS/TEN/DRESS/anaphylaxis = absolute avoidance). PCN-cephalosporin cross-reactivity LOW (1-2%) — cephalosporins usually OK if no severe history. De-label PCN allergy when possible (90% labeled aren't truly allergic) to improve stewardship. First-dose precautions: 15-30 min bedside observation, epinephrine + Benadryl + airway available.

LIVE vaccines (MMR, varicella, yellow fever, zoster live, LAIV nasal flu, oral polio, oral typhoid) = CONTRAINDICATED in pregnancy + significant immunosuppression. INACTIVATED + recombinant + toxoid (inactivated flu, Tdap, pneumococcal, hep A+B, HPV, COVID mRNA, Shingrix recombinant) = SAFE. Time live vaccines 1+ month before pregnancy + 4+ weeks before/after immunosuppression. Pregnancy recs: Tdap each pregnancy 27-36 wk, inactivated flu any trimester, COVID.

VAP prevention is a bundle: HOB elevated 30-45° unless contraindicated, chlorhexidine oral care q2-4h, daily sedation interruption + spontaneous breathing trial, sub-glottic suctioning, DVT prophylaxis + PUD prophylaxis. Antibiotic prophylaxis is NOT part of VAP prevention.

Td/Tdap every 10 years. Tdap during EACH pregnancy at 27-36 weeks regardless of prior. Pneumococcal (PCV20 or PCV15+PPSV23) at 65+ (earlier high-risk: smokers, immunocompromised, certain diseases). Shingrix 2-dose series at 50+ regardless of prior zoster. Annual influenza for all. COVID per current schedule.

DASH diet + 150 min/wk moderate exercise + 5-10% weight loss + BP target < 130/80 (per AHA/ACC) + statin if ASCVD risk ≥ 7.5%. Address pre-diabetes (HbA1c 5.7-6.4): intensive lifestyle ± metformin. Lifestyle + medication are BOTH needed for high-risk patients, not either-or.

Before each digoxin dose: apical pulse for a full minute. Hold for apical pulse <60 (adults). Always know the K and Mg levels — both low K and low Mg amplify digoxin's cardiac effect, so 'therapeutic' digoxin levels can be functionally toxic. Watch for early toxicity: nausea, anorexia, vision changes (yellow halos), bradycardia, arrhythmias.

Orthostatic hypotension with tachycardia in an anticoagulated patient is a bleed until proven otherwise. Compare today's hemoglobin to yesterday's, not to the 'normal range.' Hold the anticoagulant, assess for bleeding sources (GI, GU, intracranial, retroperitoneal), and notify the provider before treating dehydration.

Heparin-induced thrombocytopenia (HIT) presents typically 5–14 days after starting heparin with a >50% drop in platelets from baseline, often with new thrombosis. STOP heparin immediately. Switch to a non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux). Do NOT transfuse platelets. Do NOT restart heparin in this patient — ever.

Lithium therapeutic range is 0.6–1.2 mEq/L. Things that raise levels: NSAIDs, ACE inhibitors, thiazide diuretics, low sodium diet, dehydration, vomiting/diarrhea. New coarse tremor, slurred speech, ataxia, GI symptoms, or confusion in a lithium patient — check the level before assuming a psychiatric episode.

K >6.0 with ECG changes (peaked T, prolonged PR, widened QRS) is a cardiac emergency. Sequence: (1) Stabilize the membrane — IV calcium gluconate; (2) Shift K into cells — IV insulin + dextrose, inhaled albuterol; (3) Remove K from the body — Kayexalate, loop diuretics, dialysis. Hold all K-raising drugs (ACE-I, ARB, K-sparing diuretics, K supplements). Don't start with Kayexalate alone when ECG is abnormal.

If an ordered medication is contraindicated for this patient (allergy, drug-disease interaction, drug-drug interaction, wrong dose for renal function, etc.), the nurse HOLDS the dose and contacts the provider before administering. Examples: non-selective beta blockers (propranolol) in asthma; penicillins in PCN-allergic patients; NSAIDs in acute kidney injury; metformin in iodinated-contrast scenarios.

Documented anaphylaxis to penicillin = avoid ALL penicillins (penicillin G/V, amoxicillin, ampicillin, piperacillin, nafcillin) and first-generation cephalosporins (~5–10% cross-reactivity). The brand name (Augmentin, Unasyn, Zosyn) is not the safety check — the drug class is. Anaphylaxis histories are rarely outgrown safely.

Vancomycin infusion reaction (formerly 'red man syndrome'): rate-related histamine release; rash confined to the face/neck/upper chest 'flush zone'; NO airway involvement, NO hypotension. Slow the infusion (≥60 min for 1 g, ≥90 min for 1.5 g, ≥120 min for 2 g), give antihistamine, continue therapy. Document as INFUSION REACTION, not allergy — labeling it as an allergy denies the patient a critical drug for future MRSA infections.

A written order does not have to be administered. The RN has a duty to question unsafe orders. Hold the medication, document the hold, call pharmacy for verification, contact the prescriber (escalating up the provider hierarchy), and document the chain. Following an obviously wrong order does not protect the nurse from liability.

Manic clients worsen with stimulation. Provide low-stim environment, finger foods + frequent fluids, brief firm limit-setting. Restart mood stabilizer (lithium with labs) + atypical antipsychotic + PRN benzo for agitation/sleep. Avoid groups, debate, and high-stim activities. Protect from impulsive financial/social decisions.

Open airway and BVM ventilate before any large naloxone dose. Titrate IV naloxone in 0.04–0.4 mg increments targeting RR ≥ 12 and oxygenation — NOT consciousness. Big bolus = precipitated withdrawal (vomiting, aspiration, pulmonary edema). Naloxone half-life is shorter than many opioids — observe at least 4 hours after the last dose for re-sedation.

Serotonin syndrome: hyperreflexia + CLONUS (esp. lower limb) + autonomic + hyperthermia + recent SEROTONERGIC agent (SSRI, SNRI, tramadol, MAOI). NMS: LEAD-PIPE rigidity + autonomic + hyperthermia + altered mental status + recent ANTIPSYCHOTIC. Treatment differs — benzo + cyproheptadine for serotonin; benzo + dantrolene/bromocriptine for NMS. Do NOT use antipsychotics in serotonin syndrome.

Neuroleptic malignant syndrome is caused by dopamine blockade. The drug IS the cause — STOP it. Hydrate aggressively to protect kidneys from rhabdomyolysis (elevated CK). Add dantrolene or bromocriptine per provider; cool actively. Watch for AKI, DIC, arrhythmias.

Lithium is renally cleared with a narrow therapeutic window. Dehydration, NSAIDs, and thiazides raise levels. Toxicity: tremor → ataxia, confusion → seizure → arrhythmia. Treatment: HOLD lithium, isotonic IV fluids, watch renal function, frequent levels, dialysis if level ≥ 4 or severe symptoms + AKI. Activated charcoal does NOT adsorb lithium.

Medical events on a psych unit — NMS, serotonin syndrome, opioid OD re-sedation, refeeding syndrome, severe lithium toxicity — outrank behavioral acuity. Sudden calm in a high-risk suicidal client with active precautions in place can precede attempt — do NOT be reassured by 'looks better.'

Acknowledge: 'I don't hear what you hear, but I can see this is frightening.' Don't argue (escalates), don't agree (reinforces). ALWAYS ask about command hallucinations + risk: 'Are the voices telling you to hurt yourself or anyone else?' Low-stim + restart medication + sleep are the foundation of decompensation care.

Cannot screen for intimate partner violence with the partner in the room. Use a neutral reason (urine sample, X-ray, brief private exam) to separate. Validated tools (HITS, HARK). Provide resources (hotline, shelter, safety plan, naloxone if applicable). Respect autonomy — most don't leave at first disclosure; safest time to leave is planned + supported. Never confront the partner.

Open-ended questions, affirmations, reflections, summaries. Don't lecture or label. Provide harm reduction (naloxone kit, safer use, fentanyl test strips) + treatment options (MAT: buprenorphine, methadone, naltrexone). Respect autonomy + HIPAA. Schedule outpatient MAT clinic + counseling. Door open when patient is ready.

Therapeutic 0.6-1.2 maintenance, 1.5 acute mania ceiling, toxic > 1.5. Toxicity: mild tremor → moderate ataxia + slurred + confusion → severe seizure + coma. Causes: dehydration, NSAID, ACEi/diuretic, renal failure, low Na, OD. Treatment: STOP Li + IV NS aggressive + HEMODIALYSIS for severe (Li > 4 or > 2.5 + symptoms/renal failure); charcoal NOT helpful. Teach: consistent Na/fluid, avoid NSAIDs, regular Li + Cr + TSH, teratogenic (Ebstein's anomaly).

OD: RR + pinpoint pupils + LOC → NALOXONE 0.4-2 mg + airway; may need infusion for long-acting opioids; observe 4-6 hr (re-narcosis). Withdrawal: NOT life-threatening, flu-like + autonomic + GI; COWS guides. BUPRENORPHINE only when COWS > 12 (precipitated withdrawal if early). Methadone clinic-only. Clonidine + ondansetron + loperamide + NSAID symptomatic. MAT: bupr, methadone, naltrexone (sustained abstinence) + therapy + 12-step.

Imminent risk = PLAN + MEANS + INTENT + prior attempt + hopelessness + losses + intoxication + giving possessions. ASK directly (doesn't plant idea). Action: 1:1 observation + remove means (firearms #1) + psychiatric admission + safety PLAN (warning signs → coping → distract → support → 988 crisis line). Contracts INEFFECTIVE. Watch 'sudden calm' = decision made. SSRI may initially worsen ideation in young adults — monitor.

PTL = regular contractions + cervical change 20-37 wk. Tocolytics: nifedipine, MgSO4 (also neuroprotection < 32 wk), indomethacin (< 32 wk only, DA closure risk), terbutaline. ANTENATAL CORTICOSTEROIDS most important: betamethasone 12 mg IM × 2 doses 24 hr apart for 23-34 wk. GBS prophylaxis: penicillin G (cefazolin if mild PCN allergy, vanc if severe). Contraindications to tocolysis: chorio, severe preeclampsia, fetal demise, > 34 wk. MgSO4 monitor RR/DTRs/UO; calcium gluconate at bedside.

NAS multi-system: CNS (high-pitched cry, jitter, hypertonia, sleep issues), GI (poor feeding, loose stools), autonomic (sweat, yawn, sneeze, mottle), respiratory (tachypnea). Onset: opioids 24-72 hr, methadone delayed 5-7 days. Non-pharm FIRST: rooming-in with mother + skin-to-skin + swaddle + dim quiet low-stimulation + responsive feeding + breastfeed if appropriate ('eat sleep console'). Pharm if insufficient: ORAL MORPHINE (or methadone). Continue maternal MAT (methadone/bupr improves outcomes vs stopping). Non-judgmental + SW + family plan.

Neurovascular 6P: Pain (out of proportion + opioid-resistant), Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia. Pain unrelieved by opioids is the EARLIEST reliable cue. Action: notify provider STAT, bivalve cast, position AT heart level (NOT above — elevation worsens ischemia), prep fasciotomy. Open fracture = IV antibiotics + tetanus + OR within 6 hr.

Posterior approach: NO hip flexion > 90°, NO adduction past midline, NO internal rotation. Use abductor pillow, raised toilet, long-handled reacher. Anterior approach: AVOID hyperextension + external rotation + adduction; can flex > 90°. Dislocation signs: severe pain, shortened + internally rotated leg (posterior dislocation). Always pair with DVT prophylaxis (SCDs + anticoagulant + early ambulation).

Phantom limb pain is a REAL neuropathic phenomenon, not psychological — validate the patient. Treat with gabapentin/pregabalin (or TCA/duloxetine), mirror therapy, TENS, massage, relaxation. Opioids less effective. Stump care: figure-of-eight wrapping for shaping, daily skin check. Prevent flexion contracture (avoid prolonged elevation for BKA — periodically extend). Early PT + prosthesis. Address grief + body image.

Red flags: cauda equina (saddle anesthesia, bowel/bladder dysfunction, bilateral LE weakness, decreased rectal tone), cancer history, fever + IV drug use (epidural abscess), unintentional weight loss, age > 50 or < 18, trauma, progressive neuro deficit. Cauda equina = STAT MRI + neurosurgery + decompression within 24-48 hr. Routine LBP (no red flags) = conservative + activity + no routine imaging; NOT bed rest.

Both look weak; only cholinergic excess has SLUDGE/DUMBBELS (miosis, sweating, salivation, lacrimation, diarrhea, bronchospasm, bradycardia). If those are present + a recent pyridostigmine increase, HOLD the drug + atropine for muscarinic effects. If absent, treat as myasthenic (anticipate plasmapheresis/IVIG, ± steroid, supportive care). Never just 'add more pyridostigmine'.

Pregnancy and postpartum are hypercoagulable. Unilateral calf signs + pleuritic chest pain + dyspnea + hypoxia = DVT/PE workup. With high pre-test probability and no contraindications, start empiric anticoagulation (LMWH or IV heparin) while awaiting CTPA. Long-term anticoagulation typically ≥ 3 months postpartum.

Cell lysis releases K + phos + uric acid; calcium falls (binds with phos). Aggressive hydration (1.5-2x maintenance, NO K + NO phos). Rasburicase for active treatment of high uric acid; allopurinol for prophylaxis. Treat hyperK first (ECG → calcium gluconate → insulin/D50 → Kayexalate; HD if refractory). Caution IV calcium with hyperphos (Ca-phos precipitation, AKI). Monitor labs q4-6h × 48-72 hr.

Cancer (especially breast, lung, prostate, MM, lymphoma) + new back pain + neuro deficit (motor weakness, sensory loss, saddle anesthesia, bowel/bladder dysfunction) = malignant spinal cord compression. STAT IV high-dose dexamethasone + STAT MRI of complete spine + radiation oncology / neurosurgery consult. Spine precautions. Pre-treatment ambulatory status predicts outcome — hours matter.

Chronic cancer pain = scheduled long-acting opioid + immediate-release short-acting for breakthrough (10-15% of total daily dose q1h PRN). Always scheduled bowel regimen with opioid (senna + docusate ± PEG). Multimodal: NSAID/steroid for bone, gabapentin/pregabalin for neuropathic, bisphosphonate for skeletal. Tolerance + dependence ≠ addiction. Don't hold scheduled dose just because patient sleeping (use sedation + RR criteria).

Pediatric DKA differs from adult: SLOWER fluid resuscitation (10-20 mL/kg over 1-2 h, not rapid boluses) to reduce cerebral edema risk. Insulin only after fluid + K+ check (0.05-0.1 unit/kg/hr). Headache + altered LOC + bradycardia/hypertension = cerebral edema warning — emergency mannitol or 3% saline + reduce fluids + ICU. Glucose drop no faster than 100 mg/dL/hr.

Vaso-occlusive crisis needs IV opioids within 30-60 min of arrival — under-dosing is the common bias. IV fluids 1-1.5x maintenance + O2 if hypoxic. WATCH for acute chest syndrome (chest pain, dyspnea, hypoxia, fever, infiltrate) = leading cause of mortality. WATCH for stroke (sudden neuro change). Many require admission for continued IV pain control.

On a pediatric ward, prioritize patients near respiratory failure (severe asthma, bronchiolitis with apnea, croup with stridor) FIRST. Next: high-risk medication transitions (insulin drip → subQ, opioid drip → oral). Then stable supportive care. Throughput / discharge teaching = LAST. Throughput pressure is not a clinical priority.

Pediatric DKA differs from adult: 10-20 mL/kg NS bolus initial (NOT 30) + slow deficit over 24-48 hr; insulin 0.05-0.1 U/kg/hr drip — NO BOLUS (cerebral edema risk); glucose drop max 80-100 mg/dL/hr; switch to D5 1/2 NS when glucose 250-300 + continue insulin until AG closed. Watch first 12 hr neuro q1h: headache + AMS + vomiting + Cushing's triad = cerebral edema → MANNITOL or 3% NS + reduce fluids + ICU.

Pediatric ALL most common pediatric cancer; induction → neutropenic nadir. Neutropenic fever = empirical broad-spectrum within 1 hr (no waiting for cultures). Precautions: private room + hand hygiene + no fresh fruits/flowers/raw foods + no live vaccines + AVOID rectal route (temps, suppositories, enemas — mucosal trauma + infection). Mucositis: saline + bicarbonate rinses + magic mouthwash + nystatin; NO alcohol/glycerin/peroxide. Drug toxicities: vincristine neuro, asparaginase pancreatitis, cyclophosphamide hemorrhagic cystitis (mesna + hydrate).

Wilms (nephroblastoma) most common pediatric renal cancer, 2-5 yr; presents as asymptomatic abdominal mass (often parent during bath). DO NOT PALPATE — tumor rupture + dissemination + worsens prognosis. Post 'NO ABDOMINAL PALPATION' sign + educate all entering. Pre-op: BP (often HTN), gentle handling, age-appropriate prep, child life. Post-op nephrectomy: protect remaining kidney (no contact sports + nephrotoxics). Prognosis 90%+. Distinguish from neuroblastoma (younger, crosses midline, raccoon eyes, catecholamines).

Schedule: birth HepB; 2/4/6 mo DTaP+Hib+PCV13+IPV+RV; 12-15 mo MMR+varicella+HepA+PCV+Hib; 4-6 yr boosters; 11-12 yr Tdap+HPV+meningococcal; annual flu. Mild illness (low fever, URI, otitis without fever) is NOT a contraindication — vaccinate. LIVE vaccines (MMR, varicella, yellow fever, LAIV, oral polio/typhoid) CONTRAINDICATED in significant immunosuppression + pregnancy. Catch-up: don't restart series, continue from where left off. Observe 15-30 min post-vaccine.

Lispro/aspart = WITH meal (food at bedside before giving). Regular insulin = 30 min BEFORE meal. NPH = peaks 4-12 h. Glargine/detemir = basal, no peak, DO NOT MIX with other insulins. Delayed tray = hold rapid-acting until tray arrives. Mismatch = hypoglycemia.

Phenytoin, valproate, warfarin, thyroid hormones are highly protein-bound. In low albumin, total level UNDERESTIMATES the active free fraction. If symptoms suggest toxicity but total level looks low, order the FREE level. Also: tube feeds reduce phenytoin absorption — hold 1-2 h before/after.

Draw trough 30-60 min BEFORE next dose (true trough). Therapeutic for serious MRSA = 15-20 mcg/mL (varies). Supratherapeutic + rising Cr = nephrotoxicity — HOLD + recheck. Infuse over at least 60 min per gram to avoid red man syndrome (histamine release: flushing, hypotension, rash).

Warfarin → vitamin K + PCC (or FFP); heparin/LMWH → protamine sulfate; apixaban / rivaroxaban (Factor Xa) → andexanet alfa; dabigatran (direct thrombin) → idarucizumab. Vit K does NOT reverse DOACs. Protamine does NOT reverse warfarin. Specific drug = specific antidote.

Pediatric doses are weight-based (mg/kg). Always calculate independently, even if pharmacy approved — RN is the last safety net. Decimal-point errors are the most common cause of fatal pediatric medication errors. Use leading zeros (0.5 mg, not .5 mg) + no trailing zeros (1 mg, not 1.0 mg).

PCA safety depends on the patient being conscious enough to press the button. Family-pushed or staff-pushed PCA-by-proxy is a sentinel event source. Monitor SEDATION (Pasero scale) — increased sedation precedes RR drop. Stop the source first, then titrated naloxone (0.04 mg increments) to RR ≥ 12, not full reversal.

Acetaminophen toxicity has 4 stages: 0-24 h asymptomatic / nausea, 24-72 h hepatotoxicity emerging, 72-96 h peak hepatic injury, 96 h+ recovery or fulminant failure. Draw level at 4 hours post-ingestion + plot on Rumack-Matthew nomogram. NAC within 8 hours of ingestion = best outcome. Suicide precautions for intentional ingestion.

Typical hold parameters: HR < 60 or SBP < 100 (verify institutional). Patient's 'I feel fine' does NOT override objective hold criteria. NEVER give a half-dose without provider order. Hold + document + notify provider for dose review. Avoid abrupt stop in chronic users (rebound tachycardia + HTN risk).

Pre-op verification + surgeon site marking with patient verifying + time-out IMMEDIATELY before incision. If consent doesn't match patient or laterality → HALT until corrected. NPO per anesthesia guidelines (clear liquids 2 hr, light 6 hr, full 8 hr). Hold metformin (lactic acidosis), verify ACE/anticoagulant/insulin/herbals per protocol. Educate post-op (IS, splinted cough, mobility).

Wind (POD 1-2): atelectasis/pneumonia → IS, splinted cough, mobility. Water (POD 3-5): UTI from Foley → UA + culture + remove Foley + targeted antibiotics. Walking (POD 5-6): DVT/PE → duplex US + CTA + anticoagulation. Wound (POD 5-7+): SSI → inspect + culture + antibiotics + I+D if abscess; surgeon for dehiscence. Wonder drugs (any day): drug fever or C. diff or deep abscess. AVOID empirical broad-spectrum shotgun.

Enhanced recovery: early mobility (within 24 hr), multimodal pain (acetaminophen + NSAID if safe + nerve blocks + minimal opioid), gum chewing, early enteral feeding, DVT prophylaxis (SCDs + enoxaparin/heparin per protocol within 24 hr unless contraindicated), incentive spirometry, address nausea + pain so patient can mobilize. Bed rest worsens DVT + ileus + atelectasis + delirium.

GA: unconsciousness + airway protection; reversal = sugammadex (rocuronium/vecuronium) or neostigmine + glycopyrrolate; naloxone for opioid; flumazenil selectively for benzo (seizure risk in chronic users). Spinal: rapid dense block, hypotension (sympathectomy) + brady (high block) → fluids + phenylephrine/ephedrine + atropine. Epidural: titratable, watch hematoma + dural puncture + total spinal. MAC: airway monitoring + capnography. LAST = intralipid 20%.

On opioids, increasing sedation (alert → drowsy → difficult to arouse) is the warning sign that comes BEFORE the respiratory rate falls. RR ≤10 + sedation = opioid-induced respiratory depression. Stop the opioid first; reversal agents come second.

Variability in vitamin K (not vitamin K itself) destabilizes INR — eat CONSISTENT amounts. NSAIDs + warfarin = bleeding risk; substitute acetaminophen. Supplements that increase bleeding: fish oil, turmeric, ginkgo, garlic, ginger — review every supplement. Pre-op bridging plan is provider-driven; stop warfarin ~5 days pre-op with INR monitoring.

IV iodinated contrast risks = nephropathy (CKD) + reaction (history). Hold metformin starting day of contrast, resume 48 h later if renal function stable (lactic acidosis risk in AKI). Hydrate before and after with 0.9% NS. Premedicate per protocol for prior mild reactions (steroid + diphenhydramine). Shellfish allergy is NOT a contraindication to iodinated contrast — outdated myth.

Equipment in the room is not equipment in use. The fall plan = bed alarm engaged + call light in reach + scheduled toileting + orthostatic check before standing + non-skid footwear + clear, specific patient teaching + reassessment after diuretic doses. A single intervention (e.g., non-skid socks) does not constitute a plan.

Opioids + iron + bedrest + low fiber predictably cause constipation. A scheduled opioid order should be paired with a scheduled bowel regimen (softener + stimulant), ambulation, hydration, fiber as diet advances. Before any enema or manual disimpaction, assess to rule out ileus/obstruction — assess before you treat.

Reconcile at every transition — about 40% of medication errors happen at transitions. Include OTC + supplements + herbals (fish oil, ginkgo, turmeric, St. John's Wort interact). Compare HOME list to inpatient orders + identify omissions, duplications, dose changes. Notify provider for each gap. Discharge teach-back + complete med list.

True allergy = IgE-mediated (hives, swelling, anaphylaxis) → avoid drug + cross-reactive class. Intolerance = side effect (N/V, itching, flushing) → manageable with antihistamine, slower infusion, dose adjustment. Severe cutaneous (SJS, DRESS, TEN) = ABSOLUTE avoidance of drug + class. Document specific reaction + severity; don't generically label everything 'allergy.'

Oxygen + open flame = fire hazard (no smoking with O2). Damaged electrical equipment = remove from service + tag for biomed. MRI safety: verify each implant + retained metal with radiology + manufacturer; many modern implants (titanium hip/knee) are MRI-conditional. Pacemakers may be MRI-conditional with specific protocols or contraindicated (older models).

Rights: Patient + Drug + Dose + Route + Time + Documentation + Reason (some lists). 3 checks: at Pyxis/cabinet, before pouring/drawing, before administering. Active 2-identifier + barcode scan AT BEDSIDE (never armband on the bed). Verify dose math; draw EXACTLY the ordered dose. Never auto-convert route — requires new provider order.

PACU patients with respiratory depression (RR ≤ 10 + sedation) = pre-arrest, stop opioid + titrated naloxone. Post-thyroid throat tightness + perioral numbness = hypocalcemia + airway threat — calcium gluconate ready, airway team. Severe pain in awake patient = treat next. Transfer-ready patient = last. Bed flow is not the priority driver.