Shock: NCLEX Review

Shock – What is it?

Shock is a generalized systemic response to inadequate tissue perfusion. The major types are hypovolemic (absolute and relative), cardiogenic, distributive (neurogenic, anaphylactic, and septic), and obstructive shock. While they all generally have the same end result if not treated, the signs, symptoms, and interventions can be different for each type.

Shock is a complex process that can be explained down the the cellular level. We could get into cytokines and neutrophil entrapment, but this post is going to focus on nursing interventions rather than detailed pathophysiology.

As usual, I will be using my favorite textbooks/resources to write this post! Clicking on the links below will take you to an affiliate website where you can purchase them for yourself or browse around for other books.

Phases of Shock

Initial: Decreased cardiac output, decreased perfusion, anaerobic metabolism, lactic acidosis. You want to catch any signs and symptoms before it progresses any further.

Compensatory: The body is responding to the problem by increasing cardiac output and increasing oxygen delivery to tissues. (Sympathetic nervous system is in action here!)

Progressive: Compensation is not working and cells are starting to die off because anaerobic metabolism is not enough. (Systemic Inflammatory Response System)

Refractory: Shock is unresponsive to treatment and death is the probable outcome. (Multiple Organ Dysfunction Syndrome)

Hypovolemic Shock

This is the most common type of shock. It is caused by either a loss of volume (hemorrhage) or a displacement of volume (burn patients).

Signs/Symptoms/Assessment

  • Weak and rapid pulse
  • Hypotension
  • Restlessness/Altered mental status
  • Tachypnea
  • Cool, clammy skin
  • Oliguria
  • Sluggish capillary refill
  • Absent bowel sounds
  • Poor peripheral pulses

Interventions

  • Treat the cause!
  • If hemorrhage, hold pressure, replace fluids/blood
  • Insert 2 large bore IVs
  • Notify the HCP/rapid response team
  • Administer oxygen (high flow if necessary)
  • Maintain patent airway
  • Monitor vital signs
  • Monitor I/O
  • Assess skin color, temperature, turgor, moisture
  • Assess lung sounds
  • Elevate the legs (contraindicated if patient has spinal anesthesia)

Cardiogenic Shock

This is defined by a failure of the heart to pump adequately, which reduces cardiac output. This means that tissues are not being adequately oxygenated just as in hypovolemic shock. Some causes are myocardial infarction, valvular problems, and ventricular failure (reduced ejection fraction).

Treatment goals are to support cardiac output and improve coronary artery blood flow.

Signs/Symptoms/Assessment

  • Same as above
  • Pulmonary congestion
  • Chest discomfort

Interventions

  • Administer oxygen
  • Administer morphine
  • Administer vasodilators
  • Maintain patent airway
  • Administer vasopressors and positive inotropic medications
  • Treat problem–prepare for cath lab, IABP, CABG
  • Monitor I/O
  • Assist with insertion of Swan-Ganz
  • Monitor CVP, PAWP, and MAP
  • Monitor circulation (cap refill, pulses, mucous membranes)

Review Cardiac Medications Here!

Anaphylaxis

This type of shock is different from hypovolemic and cardiogenic shock. You will see that the assessment data, signs and symptoms, and interventions are also different. Anaphylaxis, or anaphylactic shock, is a sudden, severe cascade response (hypersensitivity) to an allergen. Antibodies combine with antigens and set off mast cells and histamines and cause massive vasodilation.

Signs/Symptoms/Assessment

  • Pruritus, angioedema, erythema, urticaria
  • Headache, dizziness, paresthesia, feeling of impending doom
  • Hoarseness, coughing, wheezing, stridor, dyspnea, tachypnea, sensation of narrowed airway, respiratory arrest
  • Hypotension, dysrhythmias, tachycardia, cardiac arrest
  • GI cramping, abdominal pain, N/V/D

Interventions

  • Remove the suspected allergen (stop blood transfusion, stop iodine contrast, etc.)
  • Assess respiratory status, maintain patent airway
  • notify HCP and/or rapid response team
  • administer oxygen
  • infuse normal saline (try for 2 large bore IV’s)
  • Medications: epinephrine, antihistamines (benadryl), steroids (hydrocortisone), beta-agonist
Image credit: Lonnie Millsap (lonniemillsap.com)

Neurogenic Shock

This is another type of distributive shock that impairs perfusion from vasodilation. It is most common in patients with recent injuries above T6. This can lead to pooling of blood in blood vessels.

Signs/Symptoms/Assessment

  • Hypotension
  • Bradycardia
  • Decreased cardiac output
  • Inability to sweat below the level of the injury (skin is warm and dry)

Interventions

  • Monitor vital signs
  • Notify HCP/rapid response team
  • IV fluids
  • Administer vasopressors
  • Administer atropine for bradycardia
Image source: Wikipedia

Septic Shock

Septic shock is the most extreme reaction to an infection; it is a subset of sepsis in which there is profound circulatory, cellular, and metabolic abnormalities. It is vasodilation caused by endotoxins from microorganisms.

Signs/Symptoms/Assessment

  • Tachypnea > 22 breaths/minute
  • Altered mental status – GCS < 15
  • Systolic blood pressure < 100
  • Lactic acid > 2 mmol/L
  • Unresponsive to fluid resuscitation
  • symptoms of infection – fever >100.2 F or <96.8 F

Interventions

  • Assist with placing central line
  • Monitor CVP
  • Fluid resuscitation
  • Vasopressors
  • Monitor urine output
  • Ensure cultures have been sent
  • IV antibiotics

Knowing the signs and how to manage different types of shock is essential for any nurse! I hope this review helps spark your memory for the NCLEX! Check out some of my other NCLEX review posts below:


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Stages of Labor NCLEX Review

Stage 1

Defined as the first onset of contractions through the complete dilation of the cervix, with 3 separate phases. Stage 1 is the longest phase. Throughout this phase, keep in mind the following interventions:

  • Monitor maternal and fetal vital signs.
  • Continually assess FHR before, during, and after contractions.
  • Assess fetal descent, cervical dilation, and effacement.
  • Assess fetal station presentation and position.
  • Encourage frequent position changes and/or ambulation if not contraindicated.
  • Involve patient and support person in labor process and what to expect.

Latent Phase

To start, I will add another definition here, prodromal labor. This is latent phase labor that has lasted several days.

The latent phase is usually defined by:

  • Cervical dilation is 1 to 4 cm.
  • Uterine contractions occur q15-30 mins and last 15-30 sec.
  • Lasts an average length of 5-8 hrs
  • Contractions are of mild intensity

In this stage, mom’s will most likely be feeling a variety of emotions. They are also usually able to participate in their own care and may not quite ask for pain control interventions at this time. Keep in mind that each mom is unique and requires individual assessment!

Active Phase

This phase consists of:

  • Cervical dilation of 4 to 7 cm.
  • Uterine contractions q3-5 min and last 30-60 sec.
  • Lasts an average length of 2-5 hrs.
  • Some fetal descent.
  • Contractions are moderate-strong intensity.

During this phase of labor, mom’s behavior will start to shift. She will start breathing heavier and may not be able to talk through contractions. She will benefit from a quiet environment and pain control interventions. Pain interventions do not have to be medication, as promoting comfort with back rubs, sacral pressure, and position changes can be effective and beneficial.

Transition Phase

This phase is arguably the “most difficult” phase of labor.

  • Cervical dilation is 8 to 10 cm.
  • Uterine contractions occur q2-3 min and last 45-90 sec in duration.
  • The contractions are of strong intensity.
  • Fetal descent.

During this phase, mom may have increased anxiety, apprehension, and discomfort. She will experience increased pressure, bloody show, and may verbalize the urge to push. Contrary to the active phase of labor, she may not want to be touched. Rest is encouraged between contractions.

Stage 2

Stage 2 is defined as the period from complete cervical dilation and effacement to the delivery of the fetus, or “Expulsive” phase.

  • Contractions continue to occur q2-3 min lasting 60-75 sec.
  • Increase in bloody show occurs.
  • Mom will experience voluntary or involuntary urge to “bear down.”
  • This stage can last minutes to 4 hours.

Sources of pain during the 2nd stage of labor change from pain in a more generalized area to localized to the distention of the vagina and perineum and pressure on adjacent structures.

It is important to complete assessments every 5 minutes. Normal FHR is 110-160 bpm before, during, and after contractions.

Cardinal movements of labor:

  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • Restitution
  • External Rotation
  • Expulsion

Stage 3

The process of labor does not stop once the baby has been born! This 3rd stage is from the delivery of the infant to the expulsion of the placenta. Contractions continue to occur until this is completed.
Image source: https://www.newlifeblessings.com/blog/category/placenta

  • Schultze Mechanism: “Shiny shultze” – center of the placenta separates first, and the shiny portion of the placenta emerges first.
  • Duncan Mechanism: “Dirty duncan” – the margin of the placenta separates first and the dull, rough, red portion of the placenta emerges first.

Signs of placental separation:

  • Uterus becomes globular shaped
  • Rise of the fundus in the abdomen
  • Sudden gush or trickle of blood
  • Further protrusion of the umbilical cord out of the vagina

Be sure to continue involving the mother and support person in this stage about the steps of delivering the placenta while also promoting parental-neonatal attachment. The uterine fundus should be firm and should be located 2 fingerbreadths below the umbilicus.

A placenta is considered retained if more than 30 minutes has elapsed since the birth of the infant.

Stage 4

Stage 4 is known as the Recovery Stage. This stage is defined from the delivery of the placenta to the immediate recovery of the mother.

It is important to perform maternal assessments q15min for 1 hour, q30min for 1 hour, and hourly for 2 hours, or according to facility policy. Apply ice packs to the perineum, and massage the uterus as needed to keep it firm.

The mother may also experience chills, a hypotonic bladder, and a variety of emotions related to the birth process. Encourage continued bonding between the infant and parents, and provide breast-feeding support as needed.

References and Additional Resources

All image sources are linked near or under the image on this page. I do not own the rights to images posted on this page.

Continue your NCLEX Review Journey by checking out some of my other NCLEX Review posts!


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How to Answer Priority and Delegation NCLEX Questions

Everytime I see one of these questions, I want to pull my hair out! They intimidate me and I often feel the least prepared for these types of questions. Here I will break down how to answer NCLEX-style priority and delegation questions.

A lot of this material comes from the Saunder’s Comprehensive NCLEX Review. If you’ve seen any of my other posts, you have probably run across this book. I wish I would have purchased this book my first semester of school. I bought it my third semester and kicked myself for not getting it sooner. It has been worth every penny to me!

Another great resource is the Brilliant Nurse Course for NCLEX prep. It has practice questions, detailed rationales, videos, strategy sessions, and case studies. The prices are very competitive with other similar online NCLEX-prep websites.

Priority

Prioritizing patient care is an essential nursing skill. It will determine who gets care first, and the order in which you perform your tasks. Often in the clinical setting, it can be easier to spot your priorities because you have access to a lot of information. NCLEX-style questions can be tough simply because you are given 1-2 sentences of limited information with which you must make the decision.

These types of questions can be multiple choice, select all that apply, ordered response, exhibit questions, etc. Any type of question is game!

Priority Guidelines

  • ABC’s – Airway, Breathing, Circulation
  • Remember Maslow’s Hierarchy of Needs
  • Consult your patients about their priorities and needs
  • Use the nursing process to guide you

When you are given a set of choices, read them all before making your decision. Hopefully you can eliminate 1-2 choices right off the bat. After that, use your ABC’s. If any answer choices fall into that, it is probably your answer.

Delegation

The key to answering delegation questions is understanding the scope of practice for yourself and each of your colleagues. You must also analyze the tasks that need to be done and the importance of completing them. Then, assign tasks to a competent individual.

When you assign a task to someone else, the nurse who owns the task is accountable for it.

Always ensure patient safety when delegating tasks. In general, non-invasive interventions such as ambulation and hygiene measures can be delegated to UAP’s (Unlicensed Assistive Personnel). An LPN or LVN can do some invasive procedures such as catheterization and suctioning.

Remember that a Registered Nurse is responsible for assessment, planning care, initiating teaching, and administering medications intravenously.

Never assign an unstable patient to UAP’s or LVN’s.

I hope this helps explain how to approach these questions! Practice makes perfect. Use one of the resources listed above to do practice questions! The more you expose yourself to these tough questions, the better you will get at it!


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Changing Careers (or Majors) to go to Nursing School

When I graduated high school, I wanted to be an Aerospace Engineer and work for NASA. I applied and got accepted to some of the top engineering schools in the country like University of Texas at Austin and Colorado School of Mines. I eventually chose a scholarship at the University of Colorado Boulder. My engineering journey lasted three semesters, and then I discovered that I was entirely unhappy with my life. I had a fancy engineering internship, I had great friends, and I lived in a beautiful city. What on earth could be wrong with that?

The bottom line is that engineering was not for me. It wasn’t God’s plan for me. At first I was upset that I had wasted so much time in that field, but looking back, I have used a lot of those skills in my daily life and my new nursing career.

A Diversion is Not A Waste of Time

There are so many people out there who choose nursing as a second, even third career. Some of my thoughts getting accepted into nursing school at age 24 were, “It’s about time,” and “I can’t believe I didn’t think of this sooner.”

It has taken about three semesters of school for me to be content with all of the other life choices I’ve made. I had a really rough patch, and I made a lot of choices that I regret.

If you have those types of life experiences, deal with the emotions, and use it to your advantage. I’ll use the cliche, learn from your mistakes. I am better able to handle the monstrosity of nursing school because of what I went through to get there. I would not be able to handle nursing school if I went right out of high school. I know that and I am thankful for it.

Tip: Write out your biggest life regrets/bad choices. On a separate piece of paper, write out positive lessons you learned from them. Then burn the first page with your regrets.

Have a Plan Before Quitting Your Current Job

This is something I did NOT do. Although there were many other factors in my quitting engineering school, I did not plan anything out. I left school for about a year before going back. I knew I did not want to do Aerospace, but I wanted to finish a degree. I decided to take some biology classes.

Some more life stuff happened and I switched to online, part-time school. By this time, I knew I wanted to be a nurse. I had spent so much time in the hospital that I fell in love with the art of nursing.

If I had a plan after the first time I left school, I would have been better off. But that didn’t happen. I had no idea how to start. I did zero research. I straight up just quit.

Tip: If you aren’t sure which major you want, take your basics first. Each state has different requirements, so check those out. Get your English, Math, and electives out of the way.

Do Your Research About Nursing

Nursing is a one-of-a-kind career. Nursing school is rigorous and life-changing. You will lose sleep. You will have less time with your family. You will cry. You will want to quit.

Do your research about nursing. There are a lot of misconceptions about what the job entails. If you have friends or family in nursing, ask them questions.

Listen To Your Heart

If you have a passion for it, go for it. If you are 100% sure you want to be a nurse, go for it. Any roadblocks along the way just makes it more fun when you get to your goals.

If you do all of this research and soul-searching and you still aren’t sure, you are an adult and can make your own decisions. However, I can tell you from personal experience that you need your whole heart to make it through nursing. Even when I hate school, I love it. Wouldn’t trade it for anything.

Take some time to better yourself. Read some personal development books. They are not all “if you believe it you can achieve it” cheesy. Take a look at some of my favorites below –>

Thanks for reading!



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How to Study Health Assessment in Nursing School

Assessment is one of the skills that set you apart from a lot of other medical careers. CNA’s, MA’s, Techs, and other UAP’s do not have the assessment skills that registered nurses have. It is one of those skills that is pounded in nursing school, but never truly mastered until years and years of practice. This guide will hopefully give you a better idea of how to study Assessment in Nursing School and answer HESI and NCLEX style questions.

Your textbook may be different, but we used Jarvis’s Physical Examination and Health Assessment, 7th ed.💎

Anatomy & Physiology

Most programs in the United States require A&P I and II. I’ve rarely seen some programs squish all of that in one class. You need to be a master at your anatomy and physiology. Review cardiopulmonary, abdomen, and neuro anatomy before school starts. You will need to be able to pretty much label and/or draw from memory most of your body systems. A lot of people in my class had trouble with Assessment most likely because they were weak in anatomy. I personally had trouble with the cardiovascular system for this very reason.

Vocabulary

There will be a lot of big medical terms that you’ll need to know! Hopefully you’ve picked up a lot from A&P, Patho, and your other Biology classes. When you study, make flashcards of all of the terms you do not know and study them every single day. These words WILL be on your exams, HESI, and NCLEX. Learn them now.

Normal vs. Abnormal

Assessment is all about knowing what you are supposed to be seeing, hearing, and feeling (namely inspecting, auscultating, and palpating). Establishing this foundation is very important! I took notes in two columns. One side was “normal” findings, and the other side was “abnormal” findings.

In your practice, you should be able to tell when something is wrong. You may not know 100% what is going on, but you should be able to tell your doctor over the phone what your findings are.

Study Habits + Repetition

Assessment is a tough subject. It is a lot to chew, especially with your other classes. You need to establish excellent study habits. This means no more going out every weekend, no more binge watching TV. You gotta get up earlier and go to bed later. Check out my Top 10 Study Tips to get some more tips on how to establish excellent study habits!⬇️

Repetition is key with Assessment. I probably studied each set of material more than ten times. I rewrote notes, drew pictures, and answered plenty of practice questions. I made it a goal to know the material inside and out. I probably spent the most amount of time studying for the class during my first semester.

Practice

As much fun reading out of a book is, nursing isn’t all about reading a patient’s chart. You need to practice! Practice on everyone that will let you. Friends, family, strangers (JK, that might be weird). Get used to going through your full head to toe on different people. Talk through your assessment, even if the other person has no idea what you’re saying!

Patience

These skills will come to you. Like I said in the beginning, you will not master these skills until you’ve been in practice for a long time. Don’t be too hard on yourself and don’t be afraid to seek help! As always, I am here to answer your questions!



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Cardiac Drugs Quick Sheet!

Just a quick overview for the major cardiac/ACLS drugs as pertaining to adults. This is essentially what my flash cards would pertain! Get your AHA ACLS Manual here!

Digoxin

  • Action
    • Positive inotrope – increases the force of cardiac contraction
    • Decrease HR
    • Allow for more complete emptying of the ventricles, thus increasing CO
    • Decrease conduction through the AV node, reduce automaticity of the SA node
  • Indications
    • Heart failure
    • A-fib and A-flutter
    • Paroxysmal atrial tachycardia
  • Special Considerations
    • Monitor potassium levels
    • Count apical for 1 min prior to administration

Atropine

  • Action
    • An anticholinergic drug and increases the firing of the SA node by blocking the action of the vagus nerve.
    • Increases HR
  • Indications
    • 1st line for symptomatic bradycardia
  • Special Considerations
    • Anticholinergic S/E
    • Increases myocardial oxygen demand à be careful in presence of myocardial ischemia

Adenosine

  • Action
    • Antiarrhythmic that decreases conduction through the AV node
  • Indications
    • Paroxysmal Supraventricular Tachycardia
  • Special Considerations
    • Commonly causes a few seconds of asystole
    • Very short half-life (6-10 seconds)
    • Push FAST
    • Patient may feel “like they got punched in the chest”

Amiodarone

  • Action
    • Delay repolarization resulting in prolonged duration of action potential and refractory period
    • Class III Potassium Channel Blocker
    • Decreases heart rate and contractility
  • Indications
    • Pulseless V-fib or V-tach
    • Oral – Atrial fibrillation
  • Special Considerations
    • Do NOT use with cardiogenic shock or severe sinus bradycardia à may cause hypotension
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Epinephrine

  • Action
    • Stimulate beta1 receptors à cardiac stimulation
    • Increased HR, CO, and contractility
  • Indications
    • Cardiogenic shock, Anaphylactic shock, Septic shock
    • Cardiac arrest, pulseless ventricular tachycardia, ventricular fibrillation, asystole
  • Special Considerations
    • Raises BP and increases HR à may cause myocardial ischemia, angina
    • May contribute to post-resuscitation myocardial dysfunction

Dopamine

  • Action
    • Positive inotropic
    • Increased myocardial contractility, increased automaticity, increased AV conduction, increased HR, CO, BP, MAP
  • Indications
    • Cardiogenic shock
    • 2nd line for symptomatic bradycardia
  • Special Considerations
    • Correct hypovolemia with volume replacement before using dopamine
    • DO NOT mix with Sodium Bicarb

Lidocaine

  • Action
    • Sodium channel blocker
  • Indications
    • V-fib, V-tach – with and without pulse
  • Special Considerations
    • *REMOVED from ACLS Guidelines*
    • Can cause toxicity!

Sources: 2018 ACLS Guidelines (Provider Manual), Medical-Surgical Nursing : Assessment and Management of Clinical Problems, 10th Ed (Lewis)



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My First Code.

I am still processing my first full code experience. I had previously been involved in a “chemical” code in which the family chose no intubation and no compressions. The patient did not survive, but he was in his 90’s and probably ready to go. I had another code called during seizures, but the patient’s heart never stopped. This was my first full on ER code blue experience. There are some potentially gross details in this story. Read at your own risk. Portions of this story (i.e. room numbers, times, names, etc.) are adjusted and no private information is given in this scenario.

All Emergency Departments have that phone. Some are red, some are white, all of them are loud enough to pierce through the chaos of a busy shift. There’s a phrase that makes everyone stop what they’re doing and prepare for the worst–“CPR in progress, ETA 10 minutes.

Room 1? Room 1. Let’s go.

In our city, ETA 10 minutes via EMS usually turns into 15-20 minutes. Our preparation was like clockwork. The intubation box was set up and opened. Crash cart plastic ripped off. Body bag placed under the sheets. We didn’t want to use it, but EMS reported asystole and 4 rounds of epi at the scene. I grabbed a handful of gloves, pocketed my stethoscope and badge, tightened the drawstring on my scrubs, and set up the stool. I was set to begin compressions upon arrival.

Upon arrival EMS is vigorously performing CPR on Mr. X. He is easily twice my size and no more than 10 years older than me. “Who else is rotating compressions?” I ask. I have help. We transfer the patient and I immediately begin compressions. It’s a whirlwind. Something came over me. I’m pushing as hard and as fast as I can. I’m exhausted after a minute. But I kept going and had excellent quality compressions.

My team is organized. Methodical. Everyone has a job and knows their job. Hands and arms are working around me, placing stickers and pads, getting lines and blood. The patient’s torso is wet from whatever he vomited before arresting.

Two minutes! Time for a pulse check!” Our recorder says assertively.

I stop compressions and check a carotid pulse while other team members check for radial and femoral pulses. Nothing. The code leader calls for another round of epi. My colleague knows I need to switch out. Five seconds later, compressions are resumed and I snap out of “compression mode.”

This guy is laying here and we don’t know anything about him. We have little to no history. We don’t even know his name.

I look at each person in the room. Everyone is hyperfocused on their task at hand. One nurse is documenting. Another nurse is keeping track of time with that person and giving medications. Another nurse is at the crash cart drawing up everything imaginable. Respiratory is bagging the patient. Another tech is standing near the door. The doctor is setting up the ultrasound and attempting to get a gown on. Two minutes goes by faster when you’re not the one doing compressions. It’s already time for another pulse check. Nothing.

I’m resuming compressions and I notice that the second time around is much harder. My upper body is already exhausted from the first round. I readjusted my position so that I was nearly on the bed. I need as much leverage as I can get. The doctor says that at the next pulse check he will check for movement with the ultrasound. This requires that three of us move our position, one person takes the front pad off, and another person squirts the ultrasound jelly on the patient’s chest. We only have 15 seconds to coordinate.

Two minutes! Time for another pulse check!

To me our movements seem choreographed. To an onlooker it probably looks chaotic. But the job gets done. No heart movement. More medications are pushed. My colleague is resuming compressions and the team gets ready for rapid sequence intubation. “This should have been done at the scene,” I thought.

Two minutes. Time for a pulse check and more epi.

Mr. X is having PEA. It’s not really a rhythm. It’s not shockable. It’s my turn for compressions again.

By the third round, I feel like my whole body is going to give out. My hands are slipping around everywhere because of the vomit and ultrasound jelly.

I can’t continue compressions!” I yell.

Do you need to switch?

No, I need friction!

I lift my hands up for half a second and someone geniously throws a towel over the patient’s chest. Perfect. This is perfect. My compressions are now high quality again. Everyone is ready for intubation. A mask. I need a mask. This guy probably aspirated and I don’t want whatever that was all over my face, too.

Can someone please put a mask and shield on me?

I continue my compressions as my colleague places a mask on me. He did a great job considering I was half on the stool, half on the bed, hair astray, and using all of my body strength to try to bring this guy back. I’m exhausted. I’m thinking to myself, “How much longer can I do this?” It isn’t about me. Everyone in this room is busting their ass for this patient. I’m not going to be the one to give out.

Two minutes. Pulse check!

Asystole. No pulses. No sign of life. Intubation is done and there is a significant amount of fluid coming out. CO2 monitor said 7 but now there are just dashes. No movement on the ultrasound. The doctor wants to resume compressions but he says it will probably be our last round. It has been a total of 45 minutes counting EMS time.

My colleague resumes compressions. He and I are both dripping in sweat.

We have given everything we can. H’s and T’s are checked. Bicarb, calcium, D50, fluids, etc. We have exhausted everything. As a team we were thinking massive pulmonary embolism which is very hard to come back from, if not impossible. I don’t think he was really moving any air.

Are there any objections? Does anyone have any other ideas?” The doctor asks the room.

We all look at each other and realize there is nothing else we can do for Mr. X.

Time of death 1148.


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NCLEX Review: Fluid and Electrolytes

Sodium (135-145 mEq/L)

  • The major cation in the ECF. It has a water retaining effect. When there is excess Na+ in the ECF, more water will be reabsorbed by the kidneys.
  • Functions: maintains body fluids, conduction of neuromuscular impulses via pump, regulates acid-base balance by combining with Cl- or HCO3-.

Hyponatremia

  • Causes: vomiting, diarrhea, NG suction, excessive perspiration, kidney disease, water intoxication, IV D5W, SIADH, burns
  • Signs and Symptoms: apprehension, muscular weakness, postural hypotension, N/V, dry mucous membranes, tachycardia
  • Treatment: water restriction, normal saline IV

Hypernatremia

  • Causes: excessive salt intake, dehydration, CHF, hepatic failure (excess aldosterone secretion), diabetes insipidus
  • Signs and Symptoms: extreme thirst, sticky mucous membranes, dry tongue, fever, postural hypotension, restlessness/agitation/irritability, increased fluid retention/edema, decreased urine output, convulsions
  • Treatment: stop IV normal saline, replace water loss

  • The Transition – Nursing Student to New Grad

    November 16, 2019 by

    As I countdown the days until graduation, and even more so count down the days until I take the state boards, the mix of nervousness and excitement running through my veins is increasing at an exponential rate. I am beyond thrilled that I accepted my dream residency position at a level one trauma center. I’m… Read more

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Potassium (3.5-5.0 mEq/L)

  • The major ICF electrolyte, 80%-90% is excreted by the kidneys.
  • When tissue breaks down, K+ leaves the cells and enters the ECF and is excreted by the kidneys
  • The body does not conserve K+
  • Influences both skeletal and cardiac muscle activity

Hypokalemia

  • ** The most common electrolyte imbalance
  • Causes: vomiting/diarrhea, renal disorder, sweating, crash diets, diuretics
  • S/S: fatigue, anorexia, N/V, muscle weakness, decreased bowel motility, cardiac dysrhythmias, paresthesia or tender muscles
  • Treatment: administer KCl (never give K+ undiluted or IV push. concentrated solutions should be administered through central veins. Use IV pump!)

Hyperkalemia

  • Causes: renal failure, potassium supplements, digoxin toxicity, potassium sparing diuretics, acidosis (DKA), fluid volume deficit. 
  • S/S: anxiety, cardiac arrhythmias (bradycardia, heart block, peaked T wave, widened QRS), muscle weakness, abdominal cramps, diarrhea
  • Treatment: dialysis, Kayexalate, stop supplements

Calcium (4.5-5.3 mg/dL)

  • Ionized (free Calcium) is Calcium not attached to proteins.
  • 99% is located in skeletal system, 1% in serum
  • Necessary for bone and teeth formation
  • Necessary for the transmission of nerve impulses and contraction of the myocardium and skeletal muscles
  • Causes blood clotting by converting prothrombin into thrombin
  • Strengthens capillary membranes

Hypocalcemia

  • Causes: lack of Ca and Vit D in diet, extensive infection, hypoparathyroidism, pancreatitis, chronic renal failure (Phosphorus rises/calcium declines)
  • S/S: Related to diminished neuromuscular and cardiac function – positive Trousseau’s sign, positive Chvostek’s sign, numbness of fingers and around mouth, hyperactive reflexes, tetany, convulsion, spasms/muscle cramps, arrhythmia/ventricular tachycardia. (CATS: convulsions, arrhythmias, tetany, spasms)
  • Treatment: Oral/IV replacement, correct underlying cause

Hypercalcemia

  • Causes: hyperparathyroidism, neoplasm, osteoporosis, prolonged immobilization
  • S/S: anorexia, N/V, lethargy, flank pain from kidney stones, cardiac arrhythmias (heart block, eventual cardiac arrest), muscle flaccidity
  • Treatment: Calcitonin, discontinue antacids, treatment of underlying cause


Phosphate (2.7-4.5 mg/dL)

  • buffer found primarily in ICF
  • functions: acid-base regulation, phosphate and calcium help with bone and teeth development, promotes normal neuromuscular action and participates in CHO metabolism, conversion of glycogen to glucose
  • normally absorbed in the GI tract, regulated by diet, renal excretion, intestinal absorption and PTH

Hypophosphatemia

  • Cause: excretion
  • Symptoms: disorientation, bruising, numbness, bone pain, muscle weakness
  • Treatment: increase dietary intake, IV replacement

Hyperphosphatemia

  • Causes: decreased intake or increased excretion
  • S/S: same as hypocalcemia
  • Treatment: limit phosphate intake, administer aluminum-based antacids.

Chloride (98-106 mEq/L)

  • anion found mostly in ECF, maintains body water balance, plays a role in acid-base balance, combines with H+ to produce acidity in the stomach
  • follows Na+ up or down

Hypochloremia

  • Causes: vomiting, diarrhea, excessive NG drainage, hypokalemia, hyponatremia, adrenal gland deficiency
  • S/S: hyperexcitabilty of the nervous system and muscles, tetany
  • Treatment: treat underlying cause

Hyperchloremia

  • Causes: dehydration, hypernatremia, kidney dysfunction, head injury, hyperparathyroidism
  • S/S: deep, rapid, vigorous breathing, lethargy, weakness
  • Treatment: decrease intake, correct underlying cause
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Magnesium (1.5-2.5 mEq/L)

  • Most plentiful in the cells
  • Needed for neuromuscular activity
  • Responsible for the transport of Na and K across the cell membrane

Hypomagnesemia

  • Causes: protein malnutrition, alcoholism/cirrhosis of the liver, aldosterone excess, inadequate absorption (chronic diarrhea, vomiting, NG drainage)
  • S/S: muscle tremors, hyperactive tendon reflexes, confusion, tachycardia
  • Treatment: treat underlying causes, IV replacement if necessary.

Hypermagnesemia

  • Causes: severe dehydration, renal failure, leukemia, antacids/laxatives
  • S/S: flushing, muscular weakness, increased perspiration, cardiac arrhythmias (bradycardia, prolonged QT intervals, AV block)
  • Treatment: treat underlying cause

Helpful Tidbits

  • 4 electrolytes that impact cardiac functioning: K, Mg, Ca, Ph
  • 3 imbalances that contribute to digoxin toxicity: hypokalemia, hypercalcemia, hypomagnesmia
  • 4 imbalances that contribute to seizures: hyponatremia, hypocalcemia, hypomagnesmia, hyperphosphatemia
  • Electrolytes associated with alkalosis: hypomagnesemia, hypokalemia
  • Clinical Dehydration = ECV Deficit + Hypernatremia

Source: Texas Woman’s University College of Nursing, Fundamentals of Nursing – Perry & Potter 2016




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Nursing Student Summer Tips!

Off for the summer? Here are some productive things you can do! ⛱🌻

1. Do practice NCLEX questions. Yawn. Who wants to do work over the summer? Start by setting a small goal such as 10 questions/day. You’ll find that it won’t take up too much of your time! By the time summer is over, you’ll have done hundreds of questions. I use Saunder’s NCLEX-RN Comprehensive Review for every class and it works wonders! Get a copy of it here!

You can also use Brilliant Nurse NCLEX-RN® Test Prep!, which is an online interactive experience to prep you for the NCLEX!

2. Update your resume. This can be difficult during the busy school year! Take some time to really go through your resume and send it to a few trusty people for advice.

3. Look for internships and jobs. Set aside some time to gather up information about internships and jobs. Apply for what you can and get your name out there! What is your ideal unit? What is your ideal salary? 

4. Review tough topics. Did you have a hard time with the endocrine system? Cardiac? Psych? You’re not alone. Look over some of these topics in a stress-free environment. No pressure, no due dates, no exams! You may remember more material this way. Go with 20 minutes a few times a week.

5. Relaxxxxxx. You’ve been working so hard. Plan time to treat yo self! 

Happy Summer!⭐️⛱



This post may contain affiliate links. This means that, at no cost to you, I may make a commission if you click through and make a purchase. Contact me with any questions!