Priority and triage rules for the NCLEX

Elderly insomnia: non-pharm FIRST + address triggers + avoid Beers-list sedatives (diphenhydramine, benzo, zolpidem). Melatonin OK as adjunct.

PI prevention = Braden-guided bundle: reposition q2h + offload + nutrition + specialty surface + skin moisture control. Stage 1 reversible if pressure removed promptly.

HF + dehydration = cautious fluid replacement (250-500 mL boluses, PO first) + close monitoring for overload. Never standard large bolus.

Post-stroke incontinence = retrainable. Prompted voiding + dignity-preserving brief + skin care. Foley adds CAUTI + halts progress — avoid unless retention.

Cultural/religious care = respect + ask + accommodate + involve patient's spiritual support in difficult decisions. RN doesn't override patient choice; nor force a religious ruling.

ICU family-centered care = liberalize visits + family voice/touch/music + multidisciplinary support including caregiver. Strict visitor limits are NOT evidence-based.

Airborne precautions = N95 + negative pressure + door closed. Surgical mask on patient is source control, not protective.

Bacterial meningitis (esp. meningococcal) = droplet precautions + 1-hr abx + mandatory contact prophylaxis.

Contact precautions = private room + gown + gloves + dedicated equipment. Hand hygiene with alcohol OR soap & water (both effective for MRSA — different from C. diff).

C. diff = SOAP + WATER hand wash (alcohol fails) + bleach environment + dedicated equipment. The one exception to 'alcohol is fine'.

Sterile field break = STOP + correct. Any team member can call it. Time pressure / surgeon authority doesn't override asepsis principles.

CLABSI bundle = max barrier insertion + CHG site prep + CHG daily bath + hub disinfection + DAILY review for removal (earliest removal is most powerful).

CAUTI bundle = limit indications + sterile insertion + closed system + early removal (earliest removal is strongest prevention).

VAP bundle (5 elements) = HOB 30 + sedation interruption/SBT + oral CHG care + PUD prophylaxis + DVT prophylaxis. Goal: extubate earliest.

Inferior wall MIs often involve the right ventricle. The RV is preload-dependent — nitrates drop preload and can crash the BP. With borderline or low systolic in an inferior STEMI, hold nitroglycerin until RV involvement is excluded.

Two questions before any treatment of new atrial fibrillation: (1) Is the patient hemodynamically stable right now? (2) How long has the patient been in this rhythm? Unstable → ACLS cardioversion. Stable + rhythm > 48 h or unknown → rate control + anticoagulation strategy, NOT immediate cardioversion (embolic stroke risk).

Cardiogenic shock means the pump can't move what's already there. The reflex of 'low BP → big fluid bolus' makes it worse. Recognize the cluster: pulmonary congestion + hypotension + low EF + rising lactate. First-line: inotropes/vasopressors, source control, mechanical support if needed.

In flash pulmonary edema, the first three moves are non-pharmacologic: sit upright with legs dependent, apply high-flow O2 or non-invasive ventilation, and STOP any running IV fluids. Then add IV diuretic and IV vasodilator. Morphine is no longer first-line and may worsen outcomes.

Beck's triad (hypotension + JVD + muffled heart sounds) plus pulsus paradoxus and echo evidence of effusion with chamber collapse = tamponade. The pump is choked, not empty. Give a fluid bolus to bridge preload, avoid positive-pressure ventilation if possible, and call for emergent pericardiocentesis. Pressors without volume or decompression fail.

Common pregnancy discomforts (dependent edema, heartburn, round-ligament pain) differ from preeclampsia red flags: SEVERE headache + visual changes + epigastric pain (or RUQ pain) + sudden hand/face swelling + decreased fetal movement. The cluster = severe-features preeclampsia until ruled out. Always BP + UA protein + provider notification.

Standard adolescent visits include time alone with the provider for HEADSS screening. State confidentiality limits up front: 'What we talk about is private, except if you're going to hurt yourself, someone is hurting you, or you're going to hurt someone else.' Never promise total confidentiality; never ask sensitive questions in front of parents.

Stage 1: non-blanchable erythema, skin INTACT. Stage 2: partial thickness, pink-red wound bed (looks like blister). Stage 3: full thickness, subcutaneous fat visible, no bone/tendon/muscle. Stage 4: full thickness with EXPOSED bone, tendon, or muscle. Unstageable: covered by eschar/slough — stable dry heel eschar typically left intact. DTI: intact discolored skin from damage beneath.

Pre-oxygenate with 100% O2 for 30-60 sec. Sterile catheter + sterile gloves. Insert WITHOUT suction; suction only on withdrawal, ≤ 10-15 seconds, with rotation. Routine saline lavage is NOT recommended (causes hypoxia + carries bacteria). Reoxygenate between passes. Reassess SpO2 + breath sounds.

Cold (RICE) for acute injury < 48-72 h — reduces inflammation, swelling, bleeding. Heat for chronic pain + muscle stiffness — increases blood flow + relaxes muscle. NEVER apply heat to DVT (dislodges clot), active bleeding, or anesthetized areas. Always use barrier (towel) + 15-20 min max + check skin frequently in diabetes/neuropathy.

Bladder scan first to quantify volume. Non-pharm trial (privacy, running water, warm water on perineum, mobility, semi-Fowler). If > 500 mL + can't void, INTERMITTENT (straight) catheterization preferred over indwelling Foley (reduces CAUTI risk). Reserve indwelling Foley for recurrent retention requiring continuous drainage.

Most hospital sleep disruption is iatrogenic: nighttime vitals, alarms, lights, roommate, late diuretic. Address environment FIRST: move diuretic to AM, cluster care, dim lights, earplugs + eye mask, delay non-urgent labs. Reinforce circadian: daytime light + mobility + limited naps. Benzos + zolpidem in elderly = Beers list (falls + delirium) — non-pharm first.

Hypovolemic = low CVP/PCWP/CO + high SVR + cool/clammy → fluids/blood. Cardiogenic = HIGH CVP/PCWP + low CO + high SVR + crackles/JVD → inotrope (dobutamine) + careful fluids + revascularize. Distributive (septic/anaphylactic/neurogenic) = LOW SVR ± warm → fluids + norepinephrine (for sepsis), epinephrine IM (anaphylaxis), vasopressor (neurogenic). Obstructive (tamponade/tension PTX/PE) = high CVP + narrow PP → relieve obstruction. MAP target ≥ 65.

Inhalation injury signs (facial burns, singed nasal hair, soot, hoarseness, carbonaceous sputum) = early INTUBATION before edema closes airway. CO poisoning: 100% O2 + co-oximetry. Parkland: 4 mL × kg × %TBSA in 24 hr; half in first 8 hr from BURN TIME (not arrival); titrate UO 0.5 mL/kg/hr adult. TBSA: rule of 9s (adult) or Lund-Browder (peds). Cover with clean dry sheet (not ice). Watch circumferential burns → escharotomy.

Berlin criteria: acute < 1 wk + bilateral infiltrates + non-cardiogenic + P/F ratio (mild 200-300, mod 100-200, severe < 100) on PEEP ≥ 5. Lung-protective ventilation: TV 6 mL/kg PREDICTED body weight + Pplat ≤ 30 + permissive hypercapnia. PEEP titration. Severe (P/F < 150) = prone 16 hr/day + NMBA first 48 hr if dyssynchrony. Conservative fluids. Treat underlying cause.

High pressure alarm: kinked tubing, secretions/plug, biting, bronchospasm, pneumothorax, ETT mainstem, pulmonary edema, decreased compliance. Low pressure alarm: leak, extubation, disconnect. FIRST: assess PATIENT (skin + chest rise + SpO2 + breath sounds + HR), bag with BVM 100% O2 if uncertain. DOPE: Displacement, Obstruction, Pneumothorax, Equipment. Never silence without addressing.

Assess pain (CPOT/BPS) → analgesia first (fentanyl). Both spontaneous awakening + breathing trials daily. Choice of sedation: target RASS 0 to -2, prefer propofol/dexmedetomidine over benzodiazepines (delirium risk). Delirium (CAM-ICU): non-pharm first (orient, sleep, family, mobility); atypical antipsychotic if safety. Early mobility on vent. Family engagement. Reduces ICU mortality + LOS + delirium + vent days.

V-Fib/pulseless V-Tach: high-quality CPR + DEFIBRILLATE first (or ASAP) → CPR 2 min → IV/IO → epi 1 mg q3-5 min after 2nd shock → amiodarone 300 mg after 3rd shock. PEA/asystole: CPR + epi ASAP. Search Hs + Ts (hypovolemia, hypoxia, H+, hypo/hyperK, hypothermia, tension PTX, tamponade, toxins, thrombosis). Minimize compression pauses < 10 sec. Post-ROSC: TTM 32-36°C, STEMI cath, protective vent, MAP ≥ 65.

Sepsis = suspected infection + qSOFA 2/3 (RR ≥ 22, AMS, SBP ≤ 100). Septic shock = persistent hypotension on vasopressor + lactate > 2 despite fluids. 1-hr bundle: cultures BEFORE antibiotics, broad-spectrum IV antibiotic within 1 hr (do NOT delay for cultures), 30 mL/kg crystalloid for hypotension/lactate ≥ 4, lactate, norepinephrine for MAP ≥ 65 if persistent. Source control. Steroids (hydrocortisone) for refractory.

SCI at/above T6 → loss of sympathetic tone → HYPOtension + BRADYcardia + WARM/dry skin + poikilothermia. Distinguishes from hemorrhagic (tachy + cool). Manage: spinal precautions + airway, CAUTIOUS fluids (not hypovolemic — pulmonary edema risk), vasopressor (norepi/phenylephrine), atropine for symptomatic brady, warming for hypothermia, rule out concurrent hemorrhage. Spinal shock is different (transient flaccid + areflexic immediately post-SCI).

Minute-critical reversible (tension PTX, ROSC V-Fib) > time-window reversible (STEMI cath after ROSC, AHTR) > refractory hours (septic shock source control) > stable + family. Reversibility + window matter more than visible severity number. Patients already on supportive measures may rank below an acutely reversible cause.

When assigning between a new graduate and an experienced nurse, first match acuity to skill level — then balance the count. Stretching a new grad onto a vasopressor is unsafe, but giving them the lightest count is not the answer either. They need reasonable volume of stable / predictable assignments + clear charge-nurse availability.

Read pH (< 7.35 acidosis, > 7.45 alkalosis), then CO2 and HCO3. ROME: Respiratory Opposite (pH and CO2 move opposite directions = respiratory), Metabolic Equal (pH and HCO3 move same direction = metabolic). Anion-gap metabolic acidosis = MUDPILES (methanol, uremia, DKA, propylene glycol, infection/iron/INH, lactic, ethylene glycol, salicylates). Treat the cause, not just the number.

UNSYNCHRONIZED defibrillation = V-fib + pulseless V-tach. SYNCHRONIZED cardioversion = unstable tachyarrhythmias WITH pulse (unstable VT, unstable A-fib with hemodynamic compromise). Stable A-fib = rate control + anticoagulation, NOT shock. Complete heart block = pacing (atropine often ineffective).

Activity × 1-2 wk: NO bending at waist, NO lift > 5-10 lbs, NO straining (stool softener), NO rubbing/pressing eye, NO swimming/water in eye. Sleep on UNAFFECTED side or back (eye shield at night). Multi-drop regimen with 5+ min between + nasolacrimal pressure. Sunglasses for photophobia. Mild OTC analgesic — AVOID aspirin/NSAID. Report: severe pain, sudden vision change, flashes + floaters (retinal detachment), purulent drainage. Normal: mild ache, tearing, glare, photophobia first few days.

Sudden FLASHES + new FLOATERS + CURTAIN over vision (painless) = retinal detachment until proven otherwise → STAT ophthalmology (same-day). Risk: myopia, trauma, cataract surgery, diabetic retinopathy, age. Restrict activity + bedrest + position with detachment dependent + avoid Valsalva. Treatment: laser, cryo, pneumatic retinopexy (face-down 50% waking × 1-2 wk + NO AIR TRAVEL — gas bubble expands), scleral buckle, vitrectomy. Time-critical; macula-on = better prognosis. Distinguish from PVD (no curtain), migraine aura (HA), retinal vein occlusion.

Ménière disease tetrad: episodic VERTIGO + TINNITUS (roaring low-pitch) + fluctuating SENSORINEURAL HEARING LOSS + AURAL FULLNESS. Lifestyle: LOW SODIUM (< 2 g/day) + avoid caffeine/alcohol/nicotine/MSG + stress reduction + regular sleep. Pharm: diuretic (HCTZ + triamterene), betahistine; acute attack — antihistamine (meclizine), antiemetic (ondansetron), benzo (lorazepam vestibular sedation); intratympanic steroid/gentamicin or surgery for refractory. Safety: don't drive during attacks. Distinguish from BPPV (positional, < 1 min, Epley)/vestibular neuritis/labyrinthitis.

Melanoma ABCDEs: Asymmetry, Border irregular, Color varied, Diameter > 6 mm, Evolving. Refer for biopsy (excisional or punch — NOT shave; affects Breslow depth + staging). BCC = pearly + telangiectasias + rolled border (slow, rarely metastasizes; Mohs/excision/topical 5-FU). SCC = scaly + crusty + actinic keratosis precursor (can metastasize esp. lip/ear/immunocompromised). Sun protection: SPF 30+ broad-spectrum reapplied q2h + UPF clothing + wide-brim hat + avoid 10AM-4PM peak + monthly self-exam + annual derm. NO TANNING BEDS (increases all skin cancers).

Hierarchy: necrotizing fasciitis + sepsis (LIFE — minute-critical mortality) > posterior epistaxis on anticoagulant with hemodynamic compromise (LIFE/airway) > acute angle-closure glaucoma (VISION in hours) > retinal detachment (VISION slower window). Don't drift toward visible severity (high IOP, dramatic eye); use mortality + reversibility + window. Parallel coverage via charge + colleagues + multidisciplinary team.

Concurrent adrenal insufficiency is common — give IV hydrocortisone BEFORE IV levothyroxine to prevent triggering adrenal crisis. Rewarm passively/slowly: rapid external rewarming causes peripheral vasodilation and cardiovascular collapse. Correct hyponatremia and hypoglycemia carefully.

Suspected adrenal crisis (hypotension + hypoNa + hyperK + hypoglycemia + appropriate history) is a clinical diagnosis. Draw cortisol + ACTH, then immediately give IV hydrocortisone 100 mg + 0.9% NS with D5. Lab workup proceeds in parallel; treatment does not wait. Never stop chronic steroids abruptly.

For Na+ < 120 with neuro symptoms (seizure, coma), use hypertonic (3%) saline boluses per protocol to raise Na+ 4–6 mEq/L acutely — enough to stop symptoms. Total correction must NOT exceed 8–10 mEq/L per 24 h: overcorrection causes osmotic demyelination syndrome (often permanent, locked-in). In SIADH, do not push 0.9% NS — it can paradoxically drop Na+ further.

Diabetes insipidus presents as polyuria (very dilute urine) + hypernatremia + hypovolemia. The body is losing free water faster than the kidneys can compensate. Replace losses with hypotonic fluid (D5W or 0.45% NS) mL-for-mL plus maintenance, and give DDAVP (desmopressin) per orders. Restricting fluids is the opposite of correct.

When prioritizing across a group of endocrine clients, the priority is determined by ACUITY TODAY, not by who you knew yesterday or who is loudest. Acute potential airway (post-thyroid hypocalcemia tetany) > acute physiologic crisis (adrenal, storm) > abnormal labs without symptoms > stable transitions.

HypoNa < 135: neuro symptoms (headache, confusion, seizure). Causes: SIADH (euvolemic, concentrated urine), hypovolemic, hypervolemic dilutional. Treatment: fluid restrict (SIADH), correct max 6-8 mEq/L per 24 hr to prevent ODS/CPM; hypertonic 3% for severe symptomatic. HyperNa > 145: thirst, dry, AMS. Causes: water loss (DI, GI), excess Na. Replace water deficit; max 10 mEq/L per 24 hr to prevent cerebral edema; DDAVP for central DI. RAPID CORRECTION = devastating CNS injury.

HypoCa < 8.5: tetany, perioral paresthesia, Chvostek + Trousseau, prolonged QT, laryngospasm. Causes: post-thyroidectomy, hypoparathyroidism, hypoMg, vit D def, pancreatitis. IV calcium gluconate slow + REPLACE Mg (Ca won't correct without Mg). HyperCa > 10.5: 'Bones, Stones, Groans, Moans' — lethargy, polyuria, stones, bone pain, shortened QT. HYDRATE FIRST aggressive IV NS + calcitonin + bisphosphonate; furosemide ONLY when euvolemic.

HypoMg < 1.7: tremor, tetany, torsades de pointes, refractory hypoK + hypoCa. IV MgSO4 1-2 g for severe; torsades = 2 g bolus. HyperMg > 2.6: hypotension, ↓ DTRs (areflexia 7-10), respiratory depression (RR 8-12), cardiac arrest > 15. Treatment: STOP Mg source + IV CALCIUM GLUCONATE (antidote) + furosemide + dialysis if AKI. Preeclampsia MgSO4 monitor: RR ≥ 12, DTRs present, UO ≥ 30 mL/hr, calcium gluconate at bedside.

HypoPhos < 2.5: weakness, respiratory failure, confusion, hemolysis. Refeeding syndrome in malnourished: insulin surge → drops phos, K, Mg → arrhythmia + death. PREVENT: thiamine 100 mg BEFORE feeding + start at 25-50% of goal + advance slowly + monitor electrolytes daily × 5-7 days. HyperPhos > 4.5 (CKD usually): dietary restrict + binders WITH MEALS (calcium carb/sevelamer/lanthanum) + dialysis. AVOID Mg/Al binders chronic.

Deficit: ↓ BP + ↑ HR + dry + ↓ UO + ↑ Hct + prerenal labs (BUN:Cr > 20). Excess: JVD + crackles + edema + weight gain + bounding pulse. Fluid choice: ISOTONIC (NS/LR — LR preferred trauma/burns) for hypovolemia; HYPOTONIC (1/2 NS, D5W) for free water deficit/hyperNa; HYPERTONIC (3% saline) for severe hypoNa/cerebral edema. Daily weight (same time/scale/clothing) = best fluid measure; 1 kg ≈ 1 L.

Steps: (1) pH (acidotic < 7.35, alkalotic > 7.45) (2) PaCO2 (resp) (3) HCO3 (metabolic) (4) primary + compensation (5) AG if met acidosis (Na - Cl - HCO3, normal 8-12). Met acidosis HAG = MUDPILES (Methanol, Uremia, DKA, Propylene glycol, Iron/INH, Lactic, Ethylene glycol, Salicylates). Non-gap = diarrhea, RTA. Resp acidosis = hypoventilation. Met alkalosis = vomiting/NG/diuretics. Resp alkalosis = hyperventilation/PE/sepsis/salicylate early. Compensation: respiratory FAST, renal SLOW. Avoid high O2 in COPD (CO2 retention) → SpO2 88-92 + NIV.

Mixed disorder when compensation inappropriate. Winter's formula: expected PaCO2 = 1.5 × HCO3 + 8 ± 2 for metabolic acidosis. Delta gap (Δ AG vs Δ HCO3): if AG rises more than HCO3 drops → concurrent met alkalosis; less → concurrent non-gap acidosis. Common mixed: DKA + vomiting, sepsis + COPD, salicylate (HAG + resp alkalosis). Treat ALL components in parallel, not just pH.

Cardiac arrhythmia (torsades from hypoMg, hyperK with ECG changes) = minute-critical > brain (severe hypoNa with seizure, severe hyperNa with AMS) = brain-critical > hypovolemic shock = hour-critical. Parallel coverage via colleagues for concurrent emergencies. BP number isn't priority alone — cardiac rhythm + brain trump number.

Types: physical, sexual, emotional, financial, NEGLECT (most common), abandonment. Red flags: pressure injuries + dehydration + malnutrition + poor hygiene + injuries in stages + delayed care + caregiver behavior. RNs are mandated reporters in all states — report to Adult Protective Services on REASONABLE SUSPICION, not proof. Do NOT confront caregiver. Mandatory reporting overrides patient preference when criteria met.

Acuity is driven by physiology + symptoms, not by family pressure or the worst-looking lab/vital. On geriatric units: respiratory failure pre-arrest > evolving septic shock > arrhythmia with potential collapse > new delirium. Always: stop the cause (e.g., opioid drip in resp depression), titrate reversal, then escalate.

Lipase ≥ 3x normal + epigastric pain → back. Causes: alcohol + gallstones. Cullen (periumbilical) + Grey Turner (flank) = severe necrotizing pancreatitis. Treatment: NPO + aggressive IV fluids 200-500 mL/hr first 12-24 h + IV opioids (any acceptable — old sphincter of Oddi theory outdated) + monitor (hypocalcemia, ARDS, AKI, sepsis). Resume diet only after pain resolves + lipase trending down.

Pre-procedure: empty bladder + sterile + lateral insertion (LLQ usually). Send fluid: cell count + diff (PMN > 250 = SBP), culture, albumin (SAAG), gram stain, total protein. Large volume (> 5 L) = albumin 6-8 g per L removed to prevent post-paracentesis circulatory dysfunction. Empiric ceftriaxone for suspected SBP. Mild coagulopathy does NOT routinely need transfusion pre-procedure.

SBO = bilious vomiting + crampy diffuse pain + early vomiting (usually adhesions). LBO = progressive distention + late feculent vomiting + obstipation (usually cancer). Both: NPO + IV fluids + NG decompression + correct electrolytes. Cecum > 12 cm = imminent perforation, urgent surgery. Watch for strangulation/ischemia (fever, leukocytosis, severe pain, peritonitis, lactate).

HAV = fecal-oral, self-limited, vaccine available. HBV = blood/sexual/perinatal, chronic risk, vaccine available. HCV = blood (IVDU + pre-1992 transfusions), often chronic, NO vaccine but CURABLE with DAAs (> 95% cure). HCV not transmitted by casual contact — don't over-isolate. Each needs different prevention + treatment.

On a GI ward, prioritize: acute surgical emergency (perforation, ischemia, rigid abdomen + fever rising) > worsening organ failure (HE escalating, sepsis evolving) > stable post-procedure monitoring (post-EGD UGIB stable) > routine discharge. Throughput / bed flow is not a clinical priority.

Peripheral KCl ≤ 10 mEq/hr + ≤ 40 mEq/L. Faster/concentrated rates need CENTRAL line + closer monitoring. NEVER IV push (fatal arrhythmia). Continuous ECG. Replace Mg+ alongside. Independent double-check + dedicated pump.

Lipid emulsion — change tubing + bottle q12h. PRIS: prolonged (>48 hr) high-dose (>80 mcg/kg/min) → met acidosis + ↑TG + ↑CK + AKI. STOP propofol + switch agent. Adds ~1.1 kcal/mL (count in nutrition). Sedation requires airway management.

Iron deficiency: MICROCYTIC (MCV < 80) + low ferritin + high TIBC; common from chronic blood loss. Take oral iron on EMPTY stomach with VITAMIN C; AVOID dairy/calcium/antacids/coffee/tea within 1 hr. Dark stools expected. B12 deficiency: MACROCYTIC + neuro symptoms (paresthesia, ataxia); pernicious anemia → IM B12 lifelong. Folate deficiency: MACROCYTIC, no neuro symptoms. Investigate source of loss in IDA.

Hemophilia A = factor VIII deficiency (X-linked); Hemophilia B = factor IX. PT normal, aPTT prolonged. Hemarthrosis = swollen warm tense joint after minor trauma. Acute bleed: factor concentrate IMMEDIATELY before other interventions, then RICE. Pain: acetaminophen + opioid; NEVER NSAIDs/aspirin (platelet inhibition). Avoid IM, rectal temps, contact sports. Life-threatening bleeds (head/airway/GI) = high-dose factor + imaging.

Isolated thrombocytopenia + post-viral + mucocutaneous bleeding. Treat with corticosteroids (1st line) or IVIG (rapid). AVOID routine platelet transfusion — autoantibodies destroy transfused platelets; reserve for life-threatening bleed. Bleeding precautions: soft toothbrush + electric razor + no NSAIDs/aspirin + no IM + pressure 5-10 min post needles + prevent constipation. Report severe headache (ICH), GI bleed, hematuria.

Acute hemolytic reaction signs (first 15 min): fever + chills + back/flank pain + dark urine + hypotension + tachycardia. ACTION: STOP transfusion IMMEDIATELY → disconnect tubing → start NEW NS via NEW tubing (don't flush old line into patient) → notify provider + blood bank → send bag + tubing back → labs (DAT, haptoglobin, LDH, BUN/Cr, urine for Hb) → maintain BP + UO > 1 mL/kg/hr. Differentiate febrile non-hemolytic (mild fever only) vs anaphylactic vs TRALI vs TACO.

Acute hemolytic transfusion reaction (minute-critical, STOP) ranks above DIC + sepsis (hours, supportive) above HIT (hours, change anticoag) above stable patient education. Reversibility matters — STOPPING the cause (transfusion, heparin) is often the single most important action. Visible severity isn't the same as priority — already-supported ICU patients may rank below an actively reacting transfusion.

ART adherence > 95% prevents resistance + viral rebound. OI prophylaxis by CD4: < 200 → PJP (Bactrim DS daily); < 100 → toxoplasmosis (Bactrim); < 50 → MAC (azithromycin weekly). U=U: undetectable = untransmittable. Avoid live vaccines if CD4 < 200; inactivated safe. Never stop ART unilaterally — switch regimen if needed.

Multiple sclerosis: ascending demyelinating disease (RRMS most common); dissemination in time + space on MRI. Symptoms: optic neuritis, Lhermitte sign, weakness, spasticity, fatigue, bladder/bowel/sexual dysfunction. Acute relapse: IV methylprednisolone 1 g × 3-5 days (speeds recovery, doesn't change long-term). Continue DMT. AVOID HEAT (Uhthoff phenomenon worsens symptoms). Symptomatic: PT, baclofen, amantadine/modafinil for fatigue.

Guillain-Barré: post-infectious ASCENDING symmetric weakness + areflexia (often after Campylobacter GI or respiratory infection). LP: albuminocytologic dissociation (HIGH protein + NORMAL WBC). Treatment: IVIG 2 g/kg over 5 days OR plasmapheresis — STEROIDS DO NOT HELP. Monitor FVC + NIF q4h; intubate at FVC < 15-20 mL/kg or NIF > -20. Autonomic instability common. Recovery over months.

Calcineurin inhibitors (tacrolimus, cyclosporine): trough monitoring; side effects = nephro/neuro/HTN/hyperglycemia/hyperK/lipid. Anti-proliferatives (MMF, azathioprine): CBC. AVOID grapefruit + macrolides (↑ tacrolimus) + rifampin/phenytoin (↓). Coordinate azole antifungals carefully. Opportunistic infections: CMV, EBV (PTLD), BK, PJP, fungal, TB. Skin/HPV/PTLD cancer surveillance. NEVER give live vaccines.

Imminent airway failure (myasthenic crisis with FVC < 15) > autonomic instability + approaching airway (GBS with declining FVC) > opportunistic infection in immunosuppressed host > stable patient education. Reversibility + time window > visible severity numbers. Use parallel coverage via colleagues for concurrent emergencies.

Wash with soap + warm water — do NOT squeeze (mechanical pressure drives blood deeper). Report to Employee Health within minutes, not at the end of shift. Source patient testing for HIV/HCV/HBV (with consent). PEP for HIV ideally within 1-2 hours, max 72. Baseline labs + scheduled follow-up (6 wk, 3 mo, 6 mo). Never 'finish shift, do paperwork later.'

RACE: Rescue people in danger zone, Alarm (pull + call code), Contain (close doors + shut off oxygen), Extinguish if small + contained + you have clear exit OR Evacuate. PASS the extinguisher: Pull pin, Aim at base, Squeeze handle, Sweep side to side. Evacuate horizontally first (next compartment), then vertically via stairs/evac chairs — NEVER elevators.

Soap-and-water mechanically removes C. difficile spores (alcohol doesn't kill them) + cleans visibly soiled hands. Alcohol-based hand rub is faster + effective for MRSA, VRE, CRE, viruses, routine. WHO 5 Moments: before patient contact, before clean/aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings. Gloves do NOT replace hand hygiene.

Milestones occur within RANGES (walking 9-15 months), not at exact ages. Red flags requiring Early Intervention referral: no smile by 3 mo, no babble by 9 mo, no words by 16 mo, no 2-word phrases by 24 mo, regression at ANY age. Stranger anxiety emerges 6-9 mo (normal). Vocabulary explosion 18-24 mo (50 words + 2-word phrases by 2 yr).

Standard adolescent care includes private interview (ask parent to step out) + HEADSS psychosocial screen + Tanner staging + clear confidentiality limits (state law). Routine vaccines: HPV (9-12 ideal), Tdap (11-12), MenACWY (11-12 + 16), influenza annual. Always screen for depression + anxiety + SI in adolescents.

Colon: 45-75 avg risk (FIT annual / colonoscopy q10y / stool DNA q3y / CT colonography q5y). Lung CT annual: 50-80 + 20+ pack-years + smoking or quit ≤ 15 yr. Breast: 40+ avg risk; earlier + MRI for family history / BRCA. Prostate (PSA): shared decision 55-69. Cervical: 21-65 (Pap+HPV per type).

5 A's: Ask, Advise, Assess (readiness), Assist (pharmacology + behavioral), Arrange follow-up. Match approach to stage of change (precontemplation → maintenance). Pharmacologic options: NRT (patch + gum/lozenge combination), bupropion, varenicline. Behavioral: quitline (1-800-QUIT-NOW), apps, counseling. Reframe past attempts as practice. Motivational, not lecturing.

Annual STI screening for sexually active women < 25 or with risk factors. Tests: chlamydia + gonorrhea (urine NAAT or swab), HIV, syphilis, hepatitis per risk. Contraception effectiveness: LARC (IUD, implant) > hormonal > barrier > behavioral. Condoms = ONLY method protecting against STIs. HPV vaccine through 26 routine, 27-45 shared decision. Non-judgmental approach essential.

SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound). 5-10% body weight reduction has significant health benefits — realistic target. Sustainable changes > restrictive diets. Integrate exercise into life (walks, stairs, family activities). Realistic nutrition swaps + batch cooking. Multidisciplinary referrals (RD, behavioral counselor). Reframe past failures as practice.

Any diabetic on insulin who becomes acutely confused, agitated, or unresponsive needs a finger-stick blood glucose BEFORE a neuro workup or stroke alert. Insulin given without food is the most common preventable hypoglycemia in the hospital. Lispro and aspart peak within 30 minutes to 2.5 hours; regular insulin peaks 2–4 hours; NPH peaks 4–12 hours.

When a new drug + hives + airway involvement + hypotension appear together — that is anaphylaxis. First action: STOP the infusion (do not flush). Then: IM epinephrine 0.3–0.5 mg into the lateral thigh, call rapid response, apply oxygen, IV fluids. Antihistamines and steroids are adjuncts — they do not reverse anaphylaxis.

Disclose patient health info only with explicit patient consent OR to internal care team members for Treatment, Payment, or Operations (TPO). Family members are not automatically authorized. Directory consent (someone can know you're here) is separate from release-of-info consent (who can be told specifics). PHI conversations belong out of public spaces — never the cafeteria.

Disaster triage differs from single-patient ED priority. Categories: RED (immediate, life-threatening but salvageable) → YELLOW (delayed, significant but stable) → GREEN (minor / walking wounded) → BLACK (expectant or deceased — no resources). In mass casualty, you do NOT start CPR on the pulseless patient — that ties up rescuers needed for reds. Triage is by physiology, not age or anchor bias.

Environmental safety first (remove objects, ensure clear paths). Verbal de-escalation: low calm voice, ≥ arm's length, one speaker, name the feeling, offer simple choices. Do NOT argue with delusions; reflect feelings. Offer oral antipsychotic ± benzo before IM. Restraints/seclusion are last resort.

Severe malnutrition (BMI < 14, > 10% weight loss, prolonged NPO) needs slow refeeding (10–20 kcal/kg/day initial), with thiamine BEFORE/with carbohydrates. Replace phosphate, potassium, and magnesium before/during refeed. Daily electrolytes early, continuous cardiac monitor (QT, U waves). Phosphate drop is the hallmark.

During acute panic, the reasoning brain is offline. Stay with the patient using a low voice. Validate ('these feelings are real, this is a panic attack'). Guide grounding (5-4-3-2-1) + slow breathing (in 4, hold 4, out 6). 'Calm down' is invalidating; paper bag breathing is outdated + can mask hypoxia. Long-term: CBT + SSRI for panic disorder.

Hiding food + repeated bathroom trips = active ED behaviors. Supervise meals; supervise bathroom 30-60 min post-meal (prevents purging). Address behaviors directly but non-shamingly. Hold protocol consistently. Always monitor for refeeding syndrome (phos, K, Mg) in severely malnourished. Compassionate firmness, not punishment or accommodation.

BLUES (50-80%): days 3-10, mild + transient, no psychotic features. DEPRESSION (15-20%): weeks-months, depressed mood + anhedonia + fatigue, no psychotic features. PSYCHOSIS (1-2/1000): rapid onset, hallucinations + delusions + command thoughts to harm baby/self — PSYCHIATRIC EMERGENCY. Immediate admit + separate from baby until treated.

NMS: hyperthermia + LEAD-PIPE rigidity + autonomic instability + AMS + ↑CK → STOP antipsychotic + cooling + IV fluids + dantrolene/bromocriptine + ICU. EPS: acute dystonia (hours-days, benztropine), akathisia (propranolol/benzo), pseudoparkinsonism (anticholinergic), tardive dyskinesia (months-years, often IRREVERSIBLE — switch to second-gen + VMAT2 valbenazine). First-gen (haloperidol) = high EPS/NMS; second-gen = metabolic; clozapine = agranulocytosis + seizure + myocarditis (weekly CBC).

Serotonin syndrome: mental + autonomic + neuromuscular (HYPERreflexia + CLONUS) from serotonergic combo (SSRI + MAOI/linezolid/St John's wort/tramadol). STOP all + benzos + cyproheptadine. NMS: HYPOreflexia + LEAD-PIPE rigidity, slower onset. MAOI tyramine: HTN crisis from aged cheese/cured meat/wine/fava → phentolamine. Key NCLEX distinction.

AN: BMI < 17.5 + restricting → brady + hypotension + hypothermia + electrolyte (K, Phos, Mg low) + QT prolong + amenorrhea + lanugo. Refeeding syndrome high risk → THIAMINE BEFORE feed + start 200-400 cal increase q2 days + daily phos/K/Mg replacement + cardiac monitor. Supervised meals + 1 hr bathroom restriction + daily weight (gowned). Bulimia: enamel + Russell sign + parotid + hypoK + met alkalosis → CBT + fluoxetine. Don't praise weight loss.

Panic disorder: SSRI/SNRI + CBT (interoceptive exposure); benzo short bridge. Acute panic: stay + calm + grounding 5-4-3-2-1 + breathing (NOT paper bag). GAD: SSRI/SNRI or buspirone + CBT. PTSD: trauma-focused CBT (PE, CPT, EMDR) + SSRI/SNRI + prazosin for nightmares. OCD: HIGH-DOSE SSRI + ERP (exposure + response prevention); clomipramine TCA second-line. AVOID chronic benzodiazepines (dependence + cognitive + falls).

Delirium: ACUTE + fluctuating + inattention + hallucinations + REVERSIBLE (UTI, meds, metabolic, withdrawal). Non-pharm FIRST (orient, sleep, family, mobility, glasses/hearing aids, remove tethers); low-dose haloperidol if safety; AVOID benzos + restraints (worsen). Dementia: GRADUAL + progressive + global + IRREVERSIBLE (Alzheimer's, vascular, Lewy body, FTD); donepezil/memantine modest. Depression: SUBACUTE + low mood + 'I don't know' + losses + REVERSIBLE → SSRI + therapy.

NMS + delirium tremens + serotonin syndrome + severe lithium toxicity = medical emergencies (minute-hour critical). Acute suicide with 1:1 + means restriction = covered administratively while medical stabilized. Non-emergent behavioral requests (bathroom in bulimia) = supervised + structured. Don't conflate behavioral urgency with medical urgency.

Blues: 50-80% moms, day 2-10, transient, self-limited → reassurance + support + sleep. PPD: 10-15%, persistent > 2 wks, anhedonia + sleep when baby sleeps + bonding issues + suicide thoughts → SSRI sertraline + therapy + ASK directly suicide/harm. POSTPARTUM PSYCHOSIS: 0.1-0.2%, within 2 wks PP, delusions/hallucinations/harm plan baby → PSYCHIATRIC EMERGENCY + 1:1 + REMOVE baby from mother + admit + antipsychotic + mood stabilizer. Don't normalize.

Good latch: wide mouth + fish lips + asymmetric + most areola underneath + pain-free + audible swallowing. Engorgement: frequent feeding (don't skip) + warm before + cold between + NSAID. Mastitis: CONTINUE BF + antibiotic (dicloxacillin) + drain + warm before/cold after + rest; ultrasound if no improvement in 48 hr (abscess). BF jaundice from inadequate intake: increase BF 8-12x/day + lactation + supplement if dehydration; phototherapy per nomogram. Breast milk jaundice (later, well baby) — continue BF.

Physiologic: starts after 24 hr (peak day 3-5), resolves 1-2 wk. Pathologic red flags: jaundice within FIRST 24 hr, rise > 5 mg/dL per day, direct bil > 2, prolonged > 2 wk, hemolysis signs, pale stools + dark urine (biliary atresia). ABO/Rh isoimmunization: phototherapy ± exchange + IVIG. Phototherapy: eye protection + diaper only + continue feed. Kernicterus = preventable brain damage from high unconjugated bilirubin → prevent. NOT sunlight.

Placenta PREVIA: PAINLESS BRIGHT RED 2nd-3rd trimester bleeding + SOFT non-tender uterus + reassuring FHR usually; diagnose by ULTRASOUND; NO VAGINAL/RECTAL EXAMS; deliver by C-SECTION. Placental ABRUPTION: PAINFUL DARK RED bleed (may be concealed) + RIGID board-like tender uterus + fetal distress + DIC + hypovolemic shock. Risk: HTN/preeclampsia (#1), cocaine, trauma, smoking. Emergency delivery + massive transfusion + DIC management. RhoGAM if Rh- in both.

Maternal hemorrhage (PPH atony — minute-critical) > psychiatric emergency with baby at risk (postpartum psychosis — immediate safety + admit) > severe preeclampsia (hour-critical with MgSO4 + antihypertensive) > emotional support (baby blues — supportive). Maternal life + baby safety > comfort needs. Parallel coverage via charge + colleagues + social work + family.

Weights must hang FREELY — never on floor, bed, or in staff hands. Ropes in pulley grooves, knots secure. NEVER remove weights without provider order (only exception: life-threatening emergency like CPR). Pin site: small clear serous = normal; PURULENT + erythema + warmth + tenderness = infection. Cleanse per protocol (chlorhexidine or saline). Use trapeze for repositioning, neurovascular checks, prevent pressure injuries.

RA: bilateral SYMMETRIC small joints (MCP/PIP/wrist), morning stiffness > 1 hr improving with activity, systemic features, RF + anti-CCP + ESR/CRP elevated. Treat early with DMARDs (methotrexate first-line + folate). OA: ASYMMETRIC weight-bearing joints (knee/hip/DIP — Heberden's), < 30 min stiffness, worse with activity, labs normal. Symptomatic: acetaminophen → topical NSAID → injection → replacement.

SCI at or above T6 + noxious stimulus below → severe HTN + bradycardia + headache + flushing/sweating above + pale/cool below. ACTION: (1) Sit patient UP (HOB 90°) — gravity drops BP. (2) Loosen tight clothing. (3) Identify + remove trigger — bladder (kinked Foley, retention) FIRST, then bowel impaction, skin pressure. (4) IV antihypertensive (nifedipine/nitrate) if BP persists. NEVER lay flat.

Fat embolism (respiratory failure) ranks above compartment syndrome (limb threat) above autonomic dysreflexia (BP crisis with treatable trigger) above routine post-op care. ABC principles still apply — visible BP number doesn't outrank hypoxia. Use parallel coverage via colleagues when multiple emergencies coincide. Routine ambulation requests defer until acute issues addressed.

Sustained ICP > 22 mmHg, falling GCS, anisocoria, and pupil changes all precede the classic Cushing's triad (HTN + bradycardia + irregular respirations). HOB 30°, midline neck, avoid hypotonic fluids, cluster care, limit suctioning to ≤ 10 sec. First-line acute therapy: osmotherapy (mannitol or 3% saline). Brief hyperventilation only as a bridge.

Spinal cord injury can cause loss of sympathetic tone — hypotension PLUS bradycardia with warm, dry, flushed skin BELOW the level. Don't flood with crystalloid — use moderate fluid + vasopressors to maintain MAP ≥ 85 for cord perfusion. Watch the diaphragm (level-dependent), decompress the bladder, prevent skin breakdown.

Don't wait for the LP. Blood cultures + droplet precautions + IV empiric antibiotics (ceftriaxone + vancomycin ± ampicillin) + dexamethasone within the first hour. CT before LP if altered mental status, focal deficits, or papilledema. Treat close contacts with chemoprophylaxis if meningococcal. Petechiae = think meningococcal until proven otherwise.

Acute potential airway/breathing failure (e.g., GBS at VC 16) > acute hypertensive / autonomic emergency (autonomic dysreflexia from bladder distension) > new focal neuro deficit (vasospasm after SAH) > stable transfers / paperwork. In dysreflexia, the first move is HOB UP (counterintuitive) and remove the trigger.

Severe-features preeclampsia (BP ≥ 160/110 sustained, end-organ symptoms, or HELLP labs) requires magnesium sulfate for seizure prophylaxis + IV antihypertensive (labetalol or hydralazine) for severe-range BP. Preeclamptic edema is capillary leak, not volume overload — diuretics worsen placental perfusion. Quiet, dim room. Steroids if < 34 wk.

Magnesium toxicity progression: loss of DTRs → respiratory depression → cardiac arrest. Renal clearance — falling UO causes accumulation. Therapeutic range 4–7 mg/dL. Antidote = calcium gluconate 1 g IV slowly. Stop the Mg first; calcium second.

Variable = Cord (compression); Early = Head (compression, benign); Acceleration = Okay; Late = Placental insufficiency. For LATE decels: STOP oxytocin, reposition LEFT lateral (off supine), O2 10 L NRB, IV fluid bolus, notify. If recurrent and unresponsive, prepare for delivery.

Postpartum eclampsia is a recognized window. After airway/oxygen, restart magnesium sulfate (4–6 g load + 2 g/hr) as the antiseizure drug of choice. Benzos can be adjunctive but Mg prevents recurrence. Antihypertensive for severe BP after airway secured. Gradual BP reduction.

Infants of diabetic mothers and LGA newborns are at high risk for hypoglycemia in the first hours. Symptomatic (jittery, weak cry, poor suck, sweating, hypothermia) or severely low (often < 40 mg/dL) needs IV D10 2 mL/kg bolus + D10 maintenance, not bottle alone. Warm the baby (cold worsens it). Continue frequent BG checks.

ANC < 500 + single oral T ≥ 38.3 OR sustained ≥ 38.0 × 1 hr = neutropenic fever emergency. Workup: pan-cultures (blood per lumen + peripheral, urine, sputum if productive). Empirical broad-spectrum IV antibiotic (e.g., piperacillin-tazobactam ± vancomycin) within 1 hr — do NOT wait for cultures. Protective precautions: private room, hand hygiene, no fresh fruits/flowers/raw foods. Hold routine antipyretics that mask fever.

SIADH = hyponatremia + low serum osm + INAPPROPRIATELY concentrated urine osm + euvolemia + urine Na > 30. Treat with fluid restriction (800-1000 mL/day), salt tabs, tolvaptan. Severe symptoms (seizure, coma) = hypertonic 3% saline carefully. Correct Na slowly — no more than 6-8 mEq/L per 24 hr; faster = osmotic demyelination syndrome (CPM).

Stomatitis care: soft toothbrush + saline / sodium bicarbonate rinses 4-6×/day + magic mouthwash before meals; nystatin if candidal. AVOID alcohol-based mouthwash + glycerin/lemon swabs (drying). Bland soft cool diet. Highly emetogenic chemo: scheduled 5HT3 + dexamethasone + NK1 + olanzapine; lorazepam for anticipatory. PRN alone is inadequate.

Acute GVHD ≤ 100 days post allogeneic transplant. Skin (rash, often palms/soles first), GI (diarrhea), liver (cholestasis + ↑bilirubin/LFTs). Severity graded by organ involvement. Treatment: IV methylprednisolone 1-2 mg/kg/day + optimize tacrolimus + supportive care. Rule out infection (CMV, C. diff, etc.) + sinusoidal obstruction syndrome. NEVER unilaterally stop immunosuppression — GVHD needs MORE, not less.

Sealed implant (brachytherapy): time + distance + shielding (ALARA); exclude pregnant staff + children < 16; long-handled forceps + lead container if dislodged (no hands). Unsealed (radioactive iodine I-131): radiation in body fluids — gown, gloves, flush 2-3×, private bathroom. External beam: no radioactivity inside patient, no precautions at home; skin care: gentle cleanser + no scrubbing/lotion/perfume/sun in field.

Lethal window > visible drama. TLS hyperK with peaked T waves = minute-critical cardiac → first. Spinal cord compression = hour-window neurologic emergency → next. Neutropenic fever = 1-hr bundle → after. Symptom requests (nausea, mild pain) = lowest. Squeaky-wheel patients ≠ priority. Delegate when needed.

Wheezing requires air movement. Silent chest = severe obstruction → pre-respiratory failure. Speech limited to 1-2 words + retractions + hypoxia = severe exacerbation. Treatment: O2 + continuous nebulized albuterol + ipratropium + systemic steroids + IV magnesium for severe + anticipate BiPAP / intubation. Educate caregivers that quieter ≠ better in asthma.

Simple febrile seizure: age 6 mo-5 yr, generalized, < 15 min, single in 24 h, postictal recovery, fever > 38°C. Workup based on clinical concern (LP only if meningitis suspected, not routine). Recurrence ~30% but most don't develop epilepsy. MYTH: antipyretics prevent febrile seizures — they don't; use for comfort only. NEVER use bite blocks; lateral position + airway.

Severity: mild (5%) = mild dry mucous membranes, normal LOC, normal cap refill. Moderate (5-10%) = tachycardia, dry, sunken eyes, no tears, decreased urine. Severe (> 10%) = hypotension, lethargic, anuric. ORT (Pedialyte / WHO ORS) preferred for mild-moderate: 5 mL q5 min, build up to 50-100 mL/kg over 4 h. IV bolus 20 mL/kg only for severe or failed ORT. No sports drinks (wrong electrolytes + too much sugar).

Screen at 12 + 24 months based on risk factors (pre-1978 housing, peeling paint, low SES). Reference: 3.5 mcg/dL elevated, 5 mcg/dL action level, ≥ 45 chelation. Most children asymptomatic. Management: environmental abatement (lead-safe housing inspection, wet-wipe surfaces, hand washing), iron supplementation (reduces lead absorption), Ca + vit C, repeat level. Chelation has side effects + reserved for high levels.

Acyanotic L→R shunts (VSD, ASD, PDA): CHF (poor feeding, tachypnea, FTT, diaphoresis with feeds) — diuretic + ACEi + calorie-dense feeds. Cyanotic R→L (5 Ts: TOF, TGA, Tricuspid atresia, Truncus, TAPVR): cyanosis + tet spells (TOF) → KNEE-CHEST + 100% O2 + morphine + phenylephrine (↑SVR, ↓R→L shunt). Coarctation newborn shock when ductus closes → ALPROSTADIL (PGE1) STAT (apnea risk). 4-extremity BP + pulses.

CF: autosomal recessive CFTR; sweat chloride > 60 mmol/L. Respiratory: daily CPT/HFCWO + DNase + hypertonic saline + inhaled antibiotics + CFTR modulators (ivacaftor/elexacaftor). GI: PANCREATIC ENZYMES (pancrelipase) WITH every meal + snack — open capsule + sprinkle on COOL acidic food, do NOT crush. Diet: HIGH calorie/protein/FAT + extra SALT + ADEK fat-soluble vitamins. Infection prevention: NO CF-CF contact (cross-infection Burkholderia/Pseudomonas).

Milestones rough: 2 mo smile + lift head; 4 mo laugh + roll; 6 mo sit-support + babble; 9 mo sit alone + stranger anxiety; 12 mo walk + 1-2 words + pincer; 18 mo walk well + many words; 2 yr run + 2-word phrases + climb; 3 yr tricycle + 3-word + toilet; 4 yr hop; 5 yr skip. Red flags: no smile by 3 mo, not rolling 6 mo, not sitting 9 mo, no walking 18 mo, no first words 16 mo, no 2-word 24 mo, LOSS of acquired skill at any age. Refer Early Intervention (under 3) or school (3+); audiology + ophthalmology + neuro + dev peds.

Pediatric priority order: cerebral edema in DKA (minute-critical) > neutropenic fever sepsis (1-hr bundle) > behavioral/sensory safety (autistic child) > monitoring after resolved event (post-tet spell). Active evolving emergency > recent resolved event; medical instability > behavioral requests. Use parallel coverage + child life + family/safety attendants.

Chronic glucocorticoids suppress the HPA axis. Abrupt stop → adrenal crisis. Surgery, severe illness, trauma require stress-dose steroids (typically hydrocortisone 50-100 mg IV at induction, then taper). Sick-day rules: double dose for fever/illness, triple for severe stress. MedicAlert + carry steroid card.

Triggers: volatile anesthetics (sevoflurane, iso, des) + SUCCINYLCHOLINE; genetic ryanodine receptor mutation. EARLY signs: rising EtCO2 (first) + masseter rigidity + tachycardia + tachypnea + acidosis. Fever is LATE. Treatment: STOP triggers + switch to TIVA + DANTROLENE 2.5 mg/kg IV (up to 10 mg/kg) + 100% O2 + ACTIVE COOLING + treat hyperK + call MH hotline. Future = TIVA + non-depolarizing NMBA + alert.

Wound dehiscence + evisceration = surgical emergency. Cover protruding organs with STERILE GAUZE soaked in STERILE WARM NORMAL SALINE (keep moist, replace if drying). Position SUPINE with KNEES SLIGHTLY FLEXED (reduce abdominal tension). NPO. Large-bore IV. Notify surgeon STAT. NEVER push bowel back in (contamination + injury). Risk factors: obese, DM, smoker, steroids, malnutrition, advanced age, straining (cough/vomit). SSI bundle: pre-op prep + antibiotic prophylaxis + glucose + normothermia + clip not shave.

Two simultaneous PACU airway emergencies (laryngospasm, severe over-sedation/tongue obstruction) > circulatory crisis (high spinal block) > OR-side emergencies (MH) where anesthesia team is primary + PACU coordinates ICU. Use parallel coverage with colleagues. Airway always before BP number; PACU's job is its OWN emergencies first, then support OR.

Plan-Do-Study-Act: identify the data-driven gap, plan specific interventions, pilot small, measure, refine. Process changes (EHR cues, daily huddles, accountability tools) beat equipment swaps + education-only as drivers of outcome change. Engage frontline staff + upstream teams (ED, OR) for sustained improvement.

Stage 1: eGFR ≥ 90 with kidney damage. Stage 2: 60-89. Stage 3a: 45-59. Stage 3b: 30-44. Stage 4: 15-29 — refer to nephrology, prep for RRT (vascular access, modality choice, transplant evaluation). Stage 5: < 15 — RRT typically initiated. Diet: protein restriction in advanced stages, potassium + phosphorus restriction, fluid as ordered.

Auscultate bruit + palpate thrill q shift = patency. NO BP, IV access, venipuncture, lab draws, or restrictive clothing/jewelry on the fistula arm. Avoid sleeping on it. Watch for steal syndrome (cold + numb + pale distal hand). Patient teaches: don't carry heavy bags on that arm; report numbness, coolness, no thrill.

Cloudy effluent ± abdominal pain + fever = PD peritonitis. Send effluent for cell count + gram stain + culture. Start empiric intraperitoneal antibiotics per protocol (covers gram + / gram -). Do NOT discontinue PD — IP antibiotics need PD route to work. Reinforce sterile technique + connectology training to prevent recurrence.

Acute rejection presents with fever, graft tenderness, rising creatinine, decreased UO, HTN, weight gain. Workup: tacrolimus level, BUN/Cr, UA, ultrasound (rule out obstruction), and renal biopsy (gold standard). Treatment: pulse steroids for cellular; anti-thymocyte globulin or plasmapheresis for antibody-mediated. NEVER stop immunosuppression unilaterally — adjust under guidance.

Severe colicky flank → groin pain + hematuria. NSAIDs (e.g., ketorolac) first-line for pain (reduce ureteral spasm). Tamsulosin for 5-10 mm distal ureteral stones (medical expulsive therapy). Strain urine + send stone for analysis. For calcium oxalate: maintain dietary calcium (binds oxalate in gut), reduce oxalate (spinach, beets, nuts, chocolate, tea), low sodium, hydrate to 2-3 L/day urine.

Post-streptococcal glomerulonephritis: hx GAS infection 1-3 weeks prior → hematuria (tea/cola colored) + edema + HTN + RBC casts + low complement C3. Management: BP control (antihypertensives), sodium + fluid restriction, daily weights + strict I/O, treat residual strep. AVOID NSAIDs (worsen AKI). Most pediatric cases self-resolve.

Healthy stoma = pink/red, moist; dusky/black = ischemia (notify surgeon). Continuous urine flow (no sphincter). Mucus from ileal segment is NORMAL. Pouch: empty when 1/3 full; change wafer every 3-7 days; protect peristomal skin. Hydrate 2-3 L/day to prevent stones + UTI. Report: dusky stoma, no UO > 2 hr, fever, foul urine.

Across renal patients: peaked T waves + hyperK = minute-critical arrhythmia risk → highest priority. Vascular threat (fistula steal syndrome / ischemic limb) → next. Time-window infection (PD peritonitis, urosepsis) → next. Stable post-op + pain requests → lowest. Squeaky-wheel patients ≠ priority; lethal window > visible drama.

When a client with chronic disease shows sudden new abnormal findings, treat the change as current instability — not as their baseline. Chronic disease does not produce sudden, clustered changes. The presence of a chronic diagnosis is information, not an explanation for an acute event.

Clients with chronic CO2 retention can rely partially on their hypoxic respiratory drive. Excessive oxygen can suppress that drive and lead to CO2 narcosis. Target SpO2 88–92% in COPD, starting at the lowest effective flow and increasing only as needed. Watch the mental status — new drowsiness is the cue to titrate down, not up.

Older adults often present acute physiological problems through changes in cognition rather than through complaints of pain or shortness of breath. New confusion in an elderly client with infection should trigger a workup for hypoxia and sepsis, not a 'hospital delirium' label.

Sudden chest pain or shortness of breath in a post-op client, especially after orthopedic surgery, raises immediate concern for pulmonary embolism. Unilateral calf swelling, tachycardia, tachypnea, and a 'sense of impending doom' should not be dismissed as anxiety. DVT prophylaxis reduces but does not eliminate VTE risk.

When a tracheostomy client has acute respiratory distress: suction the trach first; if that doesn't restore patency, remove and replace the inner cannula; if still obstructed, escalate for tube replacement. A bag-valve-mask over the face is useless in a client with a permanent trach and no upper airway.

When a client reports anxiety together with new restlessness, tachypnea, tachycardia, or a falling SpO2, the anxiety is a symptom of hypoxia — not its own diagnosis. Sedating a hypoxic patient blunts their respiratory drive and can be catastrophic. Apply oxygen and assess before considering any anxiolytic.

When choosing who to see first, do not anchor to the worst-looking number or the time-bound task. A chronic, stable finding (even with a low SpO2) ranks below an acute potential airway emergency. A scheduled task is not the same as a clinically urgent one. The order is: acute potential airway/breathing → acute potential perfusion → chronic stable → routine.

Clear liquids are allowed up to 2 hours pre-op per ASA. Anything with fat (coffee with cream, milk, juice with pulp) is a LIGHT MEAL → 6-hour fast. Always report any pre-op intake honestly to anesthesia — the decision to delay or change technique is theirs.

Multi-system reaction in the first 15 minutes (fever + chills + flank pain + chest tightness + hypotension) = acute hemolytic transfusion reaction. STOP the blood immediately. Disconnect tubing and start a NEW IV / new tubing with 0.9% NS to keep access. Notify provider + blood bank. Send post-reaction labs (DAT, plasma free Hgb, urine for hemoglobin, CBC, coags), first voided urine, and return the unit + tubing to blood bank.

Visible bowel through a dehisced wound = evisceration. Cover with STERILE saline-soaked gauze (dry desiccates the bowel). Position low Fowler with knees flexed (reduces abdominal tension). NPO, IV access, call surgeon STAT for return to OR. NEVER push the bowel back in.

An open chest tube allows air entry → tension pneumothorax risk. IMMEDIATELY submerge the disconnected end in sterile water 2 cm deep (instant water seal). Do NOT clamp — clamping with an air leak causes tension pneumothorax. Get a new sterile drainage system (pre-fill water seal), connect, reapply suction. Monitor for tension.

Acuity is determined by physiology + symptoms, not lab number magnitude. Symptomatic hypoglycemia + hyperkalemia with ECG changes act in minutes. Symptomatic moderate hyponatremia in 30-60 min. Asymptomatic anemia in hours. Treat severe hypoglycemia at the bedside before calling — D50 first.

Each indwelling day raises CAUTI risk significantly. Valid indications: hemodynamic monitoring, retention requiring drainage, certain surgeries, end-of-life comfort. NOT indications: skin care, convenience, incontinence alone. Use external catheters / scheduled toileting + skin protection for incontinence. Bundle: bag below bladder, closed system, perineal care, no kinks, no routine irrigations, no prophylactic antibiotics.

Alcohol-based hand rub does NOT kill C. diff spores — soap and water mechanically remove them. C. diff requires contact precautions, a private room (or cohort with another C. diff client), dedicated equipment, and gown + gloves for every room entry. Implement empirically on suspicion — do not wait for the stool result.

Prevention is a bundle: reposition q2 h, FLOAT the heels off the bed (not just cushion), pressure-redistribution surface, moisture control (toileting program + barrier), nutrition support (protein, hydration), and no massage of compromised skin. Stage 1 (non-blanchable redness) is intact skin already injured — act now.

Plan + means + isolation = acute high risk regardless of affect. Do not leave the client alone. Implement precautions per policy (q15 visualization or 1:1). Search belongings and remove contraband. Notify the team — suicide risk disclosure is an exception to confidentiality. Means restriction at home is part of any discharge plan.

Powder-free latex is NOT latex-free. Use latex-FREE gloves, BP cuff, IV tubing, Foley, syringes, tourniquets, tape, drapes. Cross-reactive foods: banana, avocado, kiwi, papaya, chestnut, tomato (latex-fruit syndrome). Schedule as first case of day. Position anaphylaxis kit (epi + diphenhydramine + steroids + airway) at bedside.

NEVER recap needles (one-hand or two-hand) — it's the highest-risk step for sticks. Activate safety device immediately after use. Dispose directly into sharps container. Replace container at 3/4 full. For floor sharps: use forceps, do not pick up by hand. Report all needle sticks immediately (don't 'finish the shift').

Any patient lift > 35 lb requires mechanical equipment. 2+ caregivers minimum for any non-trivial transfer. Sit-to-stand aid for patients with partial weight bearing. Bariatric patients need bariatric-rated bed + lift + team. Body mechanics matters even with equipment (bend at knees, load close, no twisting). Solo transfers are the highest injury source for nurses.

On a med-surg unit, prioritize patients with acute deterioration (peritonitis, sepsis, hemorrhage, post-op bleed/leak), then evolving complications, then stable patients needing routine care, then discharge tasks (teaching, paperwork). Throughput / bed flow is not a clinical priority — acute physiology comes first.

Emergency Severity Index ranks by potential life threat + resource needs. Cardiac/vascular emergency (chest pain + diaphoresis = MI / aortic dissection) > head injury / mental status change (subdural / abuse) > evolving sepsis > stable asthma > minor wound. Anxious family or 'squeaky wheel' does NOT change priority — physiology drives.

ICU rounding priority is driven by trajectory. Worsening organ failure (rising lactate + falling MAP) = NOW. Pending crisis (controlled status epilepticus, post-extubation watch) = SOON. Stable acute (post-CABG day 1 stable) = ROUTINE. Scheduled family meetings + administrative tasks = NOT priority over acute deterioration.

Obstetric priority: fetal heart rate ≤ 70 sustained or cord prolapse with bleeding = EMERGENCY (lift presenting part, knee-chest, emergent c-section). PPH > 1000 mL = next. Improving on treatment (Mg for preeclampsia) = monitor. Stable labor = routine support. Severity of diagnosis ≠ current acuity if patient is improving on treatment.

On telemetry: symptomatic complete heart block + syncope + low BP = PACING (atropine often ineffective in CHB below AV node). Non-sustained VT in conscious patient = workup (12-lead + troponin + electrolytes). Asymptomatic drug-induced brady = hold drug + monitor. Stable chronic A-fib = routine. Drama of rhythm name ≠ priority — patient symptoms do.

Mass casualty with hazmat: ALWAYS decon at entrance before bringing into ED (protect staff + facility + other patients). PPE for staff. Triage by colors: RED (immediate, salvageable), YELLOW (delayed), GREEN (minor), BLACK (expectant). In mass casualty, NO CPR on apneic + pulseless = resources go to those who can survive. Single-patient ACLS ≠ mass casualty.