In this episode of Think Like a Nurse, Nurse Brooke dives deep into the critical skill of spotting warning signs and making life-saving decisions. With a focus on proactive risk management, we explore how nurses can quickly identify subtle changes in a patient’s condition, enabling them to act before a crisis escalates. From recognizing early signs of shock to using clinical judgment for acute care situations, this episode is packed with practical insights for NCLEX success and patient safety.
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Proactive Risk Management: The focus is on spotting early warning signs of patient deterioration and making life-saving decisions before a crisis escalates. Nurses must be vigilant and act quickly to prevent further harm.
ABCs (Airway, Breathing, Circulation): The foundation of every clinical decision. Airway issues must be addressed immediately, as nothing else matters if the airway is compromised. This rule is paramount in any acute care scenario and is a key focus for NCLEX questions.
Baseline Comparison: The importance of knowing a patient’s baseline to spot abnormal changes. A 10% drop in blood pressure or a heart rate that is significantly higher than normal could indicate early shock or other life-threatening issues. Nurses must recognize these subtle changes to intervene in time.
Delegation vs. Assessment: Delegation should be used for routine tasks (e.g., turning a patient or taking vitals), but critical assessment and decision-making are the nurse’s responsibility. Nurses are the "clinical detectives" responsible for interpreting data and acting on it.
Diagnostic Procedures and Risk Reduction: Preparation is key for minimizing risk during diagnostic procedures like radiographic studies. Always verify informed consent, confirm the patient's identity and allergies, and check baseline vitals. Special attention is needed for procedures involving contrast dye, as iodine allergies can lead to life-threatening anaphylaxis.
Cardiac Catheterization and Bleeding Risk: After cardiac catheterization, strict bed rest is required to prevent bleeding at the insertion site. Nurses must monitor for signs of bleeding, such as changes in distal pulses or pain. Use the "six Ps" (Pain, Pallor, Paresthesia, Paralysis, Pulselessness, and Poikilothermia) to assess for compromised circulation.
Recognizing Retroperitoneal Bleeding: Subtle signs of retroperitoneal hemorrhage include back or flank pain and a gradual drop in hematocrit levels. This condition can be life-threatening if not caught early.
Bronchoscopy and Aspiration Risk: Aspiration is a major concern after a bronchoscopy. Nurses should position the patient on their side until they are fully awake and the gag reflex returns to prevent aspiration.
Post-Procedure Concerns: Nurses must monitor patients post-sedation, especially after procedures like bronchoscopy or lumbar puncture. The main concern is aspiration or bleeding. In lumbar punctures, checking coagulation studies is critical to avoid spinal hematoma.
Critical Lab Values: Key lab values that require immediate attention include:
Potassium: Levels below 2.5 or above 6.5 can cause deadly arrhythmias.
Sodium: Levels below 120 or above 160 increase the risk of seizures or coma.
INR: A high INR (above 4-5) is a bleeding risk, particularly for patients on anticoagulants like warfarin.
Platelets: Levels below 20,000–50,000 increase the risk of spontaneous bleeding.
pH: A pH below 7.2 or above 7.6 indicates a serious metabolic problem and demands immediate intervention.
Acid-Base Imbalances: Nurses must identify whether the problem is respiratory or metabolic by analyzing the pH, CO2, and bicarbonate levels. Severe hypocalcemia, indicated by peak T-waves on the EKG, requires immediate treatment with calcium gluconate to protect the heart.
Post-Surgical Bleeding: In post-operative patients, especially those undergoing procedures like thyroidectomy, rapid swelling or a hoarse voice could indicate a hematoma. Immediate intervention is required to secure the airway.
Malignant Hyperthermia: A life-threatening reaction to anesthesia characterized by rapid temperature rise and severe muscle rigidity. This requires immediate administration of dantrolene to prevent fatal outcomes.
Wound Complications: Nurses must be prepared for serious complications like dehiscence or evisceration. Immediate action includes covering the wound with sterile moist saline dressings and calling for urgent surgical intervention.
Blood Transfusion Reactions: The first action in response to a transfusion reaction is to stop the transfusion immediately. Common signs of a hemolytic reaction include fever, flank pain, and dark urine. Nurses must flush the IV line with saline and notify the provider and blood bank.
Refeeding Syndrome and TPN Risks: For patients receiving total parenteral nutrition (TPN), rapid nutritional replenishment in malnourished patients can lead to refeeding syndrome, causing dangerous shifts in electrolytes (phosphate, potassium, magnesium). Close monitoring of these labs is critical to prevent life-threatening arrhythmias.
Critical Thinking in Action: Nurses must distinguish between conditions that require immediate attention versus those that pose a future risk. For example, a hematoma after surgery represents an immediate airway risk, whereas a potential DVT could evolve into a PE over time.
Welcome back. This is an episode of Think Like a Nurse created by Brooke Wallace, a 20-year ICU nurse, organ transplant coordinator, clinical instructor, and published author. We take complex nursing topics and well, we try to make them easier to understand. And today we're really diving into a critical part of the NCEX. It's the reduction of risk potential category. Right? If you're studying, you know, this is a big one. It can be what, 9 to 15% of your entire exam. And it all comes down to one thing really. Proactively preventing harm.
Exactly. It's all about being proactive. So that's our mission today. We want to help you move past just memorizing facts and really start to anticipate the crisis before it happens. It's all about clinical judgment. It is. The NCLE X isn't just going to ask you, you know, what are the signs of shock. It's going to test if you can act fast enough to stop things from getting really bad, like organ failure bad. It's all about safety and prioritizing what matters most right now. Absolutely. And for more on this, you can always visit think like a nurse. or there are a ton of great resources there.
Okay, so let's start at the beginning. The foundational rules, the the nursing pearls that have to guide every single prioritization question you see. Okay, rule number one, it's the absolute foundation, the one we preach constantly in any acute care setting. It's airway, breathing, circulation,. ABCs,. ABCs every time. It's your priority in every single scenario. If the airway is blocked, uh nothing else you do is going to matter. Okay. And the second rule is just as important, but I feel like it's one students sometimes forget.
they do. It's comparison. You have to compare everything to the client's baseline. The baseline,. I mean, if you don't know where they started, you have no idea if where they are now is a problem. A heart rate of 110 might be totally fine for one person, but if your 80-year-old posttop patient started at 65,. then 110 is a huge red flag. It's a flashing red light. It's screaming early shock. Can you give us a really specific example of that? Like, how can watching for one One small change actually save a life.
Yeah. So the standard is this a blood pressure drop of just 10%. Or a new fast heart rate that requires an immediate call to the provider. Why 10%? That seems so small. Because the body compensates. It's amazing at hiding a problem, you know, right up until it can't anymore. That 10% drop is often that tipping point from compensated shock to well decompensation. You have to catch that internal bleed before they fall off the cliff. That makes perfect sense. Okay. And what about the last pearl? Delegation. That's a huge part of managing risk on the floor.
It is. You delegate the routine stuff vitals, hygiene, turning a patient. Sure. But you never, and I mean ever, delegate assessment or evaluation or judgment. As the RN, you're the one who has to interpret that data. You're the clinical detective on the case. I love that. The clinical detective. Okay. So, we have the rules. Now, let's apply them to to some high-risisk situations like diagnostic procedures. Okay. So, with any procedure, Preparation is everything. It's your first line of risk reduction, meaning you verify informed consent. You confirm their identity, their allergies. You make sure they've been NPO,.
nothing by mouth,. right? Which prevents aspiration if they're stated, and you get a set of baseline vitals. Let's focus on one of the big ones. Radiographic studies that use contrast die. The immediate threat there isn't just the kidneys, it's the allergy, right? Correct. The absolute first thing you do is screen for an iodine allergy because if they have one, the risk is anaphilaxis, an ABC event,. a life-threatening ABC event. If it happens, you're giving epinephrine immediately and getting ready to support their airway.
And what about the kidneys? We know that dye is tough on them. It is, especially for clients who are already high risk. So, someone with diabetes or uh chronic kidney disease, CKD, you're checking their creatinine before the procedure and you're checking it after. and the intervention. Hydration, aggressive hydration before and after. You have to flush that dye out as quickly as possible. Okay, let's move to something where the nurse's role is just paramount. Cardiac catheterization. The big risk there is bleeding from the groin site. What's the protocol?
Strict bed rest and keeping that leg completely straight for 4 to 6 hours. No exceptions. It's all about keeping pressure on that artery so it can clot. And I imagine that's a challenge. It's a huge challenge. Patients want to bend their knee. They want to sit up. You have to really manage their pain and anxiety to keep them flat. So, while they're on bed rest, what are you assessing every hour? You're checking distal pulses and you're using the six Ps to check circulation. and pneummonic.
Yep. Pain, palar, paristhesia, that's numbness or tingling paralysis, a cold temperature, and finally pulselessness. And you're looking for subtle changes. You have to. Pulselessness and paralysis are late catastrophic signs you've missed it. You have to catch the increased pain or the palenness first. But there's Another kind of bleeding we have to watch for, one that you can't see,. the retroparitinal hemorrhage. Yes, this is bleeding into the back of the abdomen. It can be very subtle at first.
What are the signs? You're looking for unusual back or flank pain. And you'll see their hematocrit start to slowly drift down because you can't see the blood. The first real clue might just be the signs of shock. So, you have to call that immediately. Immediately. Okay. So, what about scopes? A broncoscopy or an endoscopy when they're coming out of sedation? What's the big worry? Aspiration. Aspiration. So, you position them on their side until they are fully awake and that gag reflex is back.
Is there any specific risk with a broncoscopy? Yes. A terrifying one actually. Luringo spasm. So, the larynx spasm shut. Exactly. You'll hear stridor, this high-pitched harsh sound, or you'll see them struggling to breathe. That's an immediate airway crisis. Head of the bed up and prepare for reintubation. Wow. Okay. And for a lumbar puncture, what's the one lab you absolutely have to check? First coagulation studies. You cannot stick a needle in someone's spine if they have a bleeding disorder. You could cause a spinal hematoma.
And postprocedure,. they have to lie flat for 4 hours. This helps prevent that awful postlumbar puncture headache from a CSF leak. And if they do get that headache,. first line is usually strong caffeine. It causes some vasoc constriction in the brain, which can help. If it's really bad, they might need a blood patch. where they inject the patient's own blood to seal the hole. Exactly. This all connects back to the labs. Recognizing those critical values is sometimes the only thing standing between a patient and you know irreversible harm.
It really is. So give us the numbers. The values that if you see them, you have to report them right away. No waiting. Okay. Let's start with the big ones. The ones that hit the heart and the brain. Potassium. Okay. If it's below 2.5 or above 6.5, that's a deadly arrhythmia risk. That's a C problem circulation. Next is sodium. Below 120 or above 160, you're talking about a major risk for seizures or even coma. because of the fluid shifts in the brain.
all because of the fluid shifts. then you've got coagulation for a client on warerin and an INR over four or five is a massive bleeding risk. and platelets if they're below say 20 to 50,000 that patient is at risk for spontaneous bleeding. wow so those are really tight boundaries. extremely tight. okay let's tackle the one that I think trips up students the most acid base balance what are the pH boundaries we need to worry about. a pH below 7.2 or above 7.6 that means the body is in a serious metabolic trouble. So how do you quickly interpret that? It's a step-by-step process. First look at the pH. Is it acidotic or alkalotic? Then look at the CO2. That's your respiratory part. Then the by carb your metabolic part. And finally see if the body is trying to compensate. The key is to quickly identify if it's a respiratory or a metabolic problem.
Let's get practical. What's the action for the deadliest imbalance? Hypocalemia. You see those peak T- waves on the EKG. What do you do first? The first priority is always to protect the heart. Always. So you give calcium gluconate immediately. And that doesn't lower the potassium. It doesn't. It stabilizes the cardiac cell membrane. It buys you time. Once the heart is protected, then you give insulin and glucose to shift the potassium back into the cells. Okay. Heart first. And on the flip side, hyponetriia, low sodium. We said that puts them at risk for seizures,
right? And if they're symptomatic, especially with neurological chang The treatment is a slow, careful infusion of 3% saline. You have to correct it slowly or the rapid fluid shift could cause even more brain damage. So, what's fascinating here isn't just seeing one bad number, but seeing a dangerous trend. Ah, now that's where true clinical judgment comes in. Recognizing trends. A rising creatinine, even if it's still technically in the normal range, signals an acute kidney injury. or a rising lactate.
signals shock or sepsis. And a classic coin. an elevated d-dimer plus sudden shortness of breath and a fast heart rate. You have to immediately suspect a pulmonary embism,. a PE,. a life-threatening clot, and you have to act. You're giving oxygen and starting anti-coagulation right then and there. Let's take that skill, that prioritization, and move it to maybe the most high stress environment, postsurgical recovery. Okay. And the rule is still the same. Airway, breathing, circulation, it's always supreme.
Give us the classic NLEX scenario. Okay. A client is 4 hours postyctomy. They suddenly develop a horse whisper and tell you their neck feels swollen. That's an immediate ABC crisis. Why? Because that horarsseness and swelling points to a hematoma, bleeding in the neck,. and it can shut off their airway in minutes. So that's the patient you see first. You don't walk, you run. You assess that client first. You're checking for stridor. You're getting ready for a possible intubation, maybe even a bedside trash. It's that serious.
That is a perfect example. Okay. What about bleeding from a surgical drain? What's the number that should make you panic? Bright red drainage of more than 300 milliliters an hour. That's not just drainage. That's a hemorrhage. That client is bleeding out and they need to go back to the O now. And the crisis that happens in the O, malignant hyperothermia,. a devastating complication from anesthesia. You see a rapidly rising temperature and severe muscle rigidity. The intervention is incredibly timesensitive. You give dantine immediately.
and that's always kept nearby for this exact reason. Always. Okay. Let's talk wound complications. You walk in and you see dehesence where the wound separates or even worse a visceration where organs are coming out, right? The immediate intervention is to cover it with sterile moist saline dressings. You protect the tissue and you call surgery urgently. and you never try to push the organs back in. Never. Just cover and call. Let's hit two high-risisk infusions really quick. First, blood transfusions. A reaction starts. What's the sequence?
First step, stop the transfusion. immediately. immediately. Don't even think about it. Then you run normal saline wide open through that IV. Keep the line open and flush any remaining blood in the tubing away from the client. And what are the classic signs of a hemolytic reaction? Fever, flank pain and dark urine. You see that, you stop the blood, run saline, and you call the provider and the blood bank right away. Our last area, total parental nutrition, TPN. It carries some huge metabolic risks.
It does. High blood sugar is a constant concern, but the really high risk complication is refeeding syndrome. That happens when you start feeding a malnourished patient too quickly. Exactly. The body's metabolism shifts so fast that it causes a dangerous drop in three electrolytes, phosphate, potassium, and magnesium. You have to monitor those labs like a hawk and replace them aggressively or you risk fatal arrhythmias. This whole conversation really brings us back to that first scenario, that prioritization question. The difference between assessing the client with calf pain after a knee replacement a possible DVT.
versus the client who's four hours post thyroidctomy with horarsseness. And that's the test. The DVT is serious. Absolutely. And it could become a PE which is lethal, but the horse post thyroidctomy client has an airway that is closing right now. The DVT is a future risk. Yeah. The hematoma is a present danger. Exactly. A DVT might take hours or days to become a PE. A neck hematoma can close an airway in minutes. Airway always wins. That's thinking like a nurse. And that difference is exactly what The NCLE X is testing. It's your ability to identify the problem that will kill the patient the fastest,
right? It's your ability to connect a small change from the baseline, a little drop in blood pressure, a high potassium level, even just a scratchy voice to a potential catastrophe. That is the core skill of risk reduction. It's the difference between just reading a number and actually understanding the crisis that it represents. Thank you for checking in with us for this conversation each week. My final thought for you is this. As you go into every patient scenario from now on, and just commit to being proactively vigilant. If you see a subtle change, just a slightly faster heart rate, ask yourself, "What if this is the start of something bad? What if this is shock? What can I do right now to stop it?". That kind of thinking, that's the true hallmark of reducing risk.
Fantastic insight. For more resources on tackling the NCLX and developing that strong clinical judgment, please visit think like a nurse.org for more. We'll talk to you next time