Notes from the Hospital

RAPID RESPONSES

HYPOXIA

Sit patient fully upright (High Fowler’s)
Count RR.
Is suction set up?
Are they gasping? Cyanotic? Accessory muscle use?
Is there already a non-rebreather on? If not, apply it.
Ensure their oxygen mask is on properly
Ensure wall flow meter is actually turned up and mask is connected fully
If they’re on oxymask and failing: Grab NRB --> 15 L/min. Ensure reservoir bag inflated before placing.
Grab the Ambu bag
Put them on: Tele leads, BP cycling q2–3 min, Pulse ox confirmed good waveform
Spike IV fluids if hypotensive
When someone is satting 70–80% despite max mask, they are thinking: Impending respiratory failure, Need for high-flow or BiPAP, Possible intubation, PE?, Pneumonia worsening?, Pulmonary edema?, Mucus plug?.
If sats fall into 60s and patient becomes lethargic: You may assist RT in bagging.

SEPSIS ALERT

Is the MAP less than 65? What was their last lactate?
Ensure Accurate vitals cycling q2–3 min
What is their BG?
Is the skin mottled? Cap refill delayed?
Have they been having good urine output?
Are they on oxygen? If not, grab a nasal cannula and put on 2-4L. Oxygen needs rise during sepsis.
Does their IV look reliable? Ensure at least 2 large bore IV's (Preferably 18G, 20G is not). Forearm or AC if possible.
Grab NS Bolus Bags, Tubing, and Pressure Bags. Spike it and be ready for the order.
Sepsis = labs + cultures + fluids + possible pressors if ICU Transfer
Grab Lab Tubes + Culture Bottles: Lactate, CBC, CMP, Blood cultures ×2, Possibly ABG/VBG, Check Blood Sugar
Know: What was their last urine output? When last ABx were given? Baseline mentation.
What to use pressure bag: 1L Ordered STAT, BP critically low, rapid infusion.
IF they have already received a bolus and no improvement, tell MD: "They’ve had 1L, MAP still 60."

STROKE ALERT

Check FAST: Facial Droop, Arm weakness, Slurred speech, and Time of onset. Other common signs: New aphasia, sudden confusion, sudden blurry vision or vision loss, sudden severe headache, unequal pupils, new unilateral numbness.
1) Assess ABCs: If decreased LOC, ensure airway is protected
2) Determine last known well: What time did you last check on them?
3) Perform Neuro check: Pupils, Facial symmetry, Arm drift, Grip strength, Speech clarity, Orientation, GCS.
4) Notify MD ASAP: "This patient has sudden onset slurred speech and right arm weakness. Last known well was 18:05. Requesting stroke evaluation." Notify Charge RN, Call stroke alert.
Check BG ASAP. And fresh set of vitals, continuous vitals if possible.
KEEP PATIENT NPO: Patient may need thrombolytics, CT, Procedures
Prepare for transport to CT. Prepare Large bore IV Access, Lab tubes, Removal of metal.
Do NOT Delay calling RRT to "observe", nor chart before activating help
When do strokes on med-surg usually occur?: On post-op patients, A-fib patients, Recent TIA patients, patients with severe hypertension, and hypercoaguable states.
Sometimes the first sign is subtle speech changes or confusion: Patient suddenly using wrong words, Dropping objects, One-sided neglect, Sudden personality change, Sudden inability to follow commands, One eye drifting
What to tell RRT: "Last known well 18:42, confirmed by CNA during vitals. Blood Glucose ___, Vitals, Anticoagulant status (this impacts tPA eligibility), IV Access, Current neuro status 'New slurred speech and right arm weakness. Previously A&O x4 with no deficits.' Platelet level, PT/INT, CMP, PTT. E.g. ""Last known well was 16:18, blood glucose 112, BP 182/94, patient has new left facial droop and arm drift, not on anticoagulants."
Documentation: Patient noted to have sudden onset slurred speech and right arm weakness at 19:12. Last known well 18:50 per HSA. Rapid response activated. Blood glucose 118. VS stable. Patient transported for STAT CT with stroke team.
Tip: Unsure whether it's a stroke? Ask the patient "Show me your teeth." Facial asymmetry shows immediately.

STROKE ALERT Q&A

1) How do you order a Stroke Alert Panel? Use dire lab slip: H/H, Platelets,Glucose,Pt/INR, Ptt, Creatinine. Hand carry to lab or tube station #99(1234)

2) What important info do you need to remember if MD orders foley insertion or want 2 IV access? Invasive procedures to be done before IV tPA (two IV access, foley insertion). NO invasive procedures 24hrs post tPA. No temp foley cath.

3) What is the dose for Alteplase? --0.9mg/kg, max 90mg --10% given as IV push over 1min(max 9mg) --remaining as an infusion over 60mins(max 81mg) --followed by 50ml NS at the same rate of the infusion

4) Before administering tPA? Use 2 patient identifiers, verify order, independently check with 2nd trained RN.

5) Post t-PA: VS q15mins x 2hrs, q30mins x 6hrs, q1h for the remainder of infusion, 24h post tPA. Assess bleeding all orifices, IV, skin, and puncture sites. Watch for orolingual angioedema 1st two hours.

6) Notify MD with any new changes: neuro changes or seizure, increased NIHHS > 2 points. Edema, CV changes SBP < 140 or > 160 or MD’s parameters, hematologic bleeding, immunologic, anaphylaxis, respiratory compromise

7) When do you do the NIHSS on patient not on Alteplase? On admission, then q2hr later then q8hrs x 24hrs. (always check what’s ordered)

8) How often should you do neuro assessment for non-tPA and ischemic stroke? Q1hr x2, then q4h until specified. Follow MD orders.

9) How often should you do neuro assessment on Hemorrhagic CVA? q30mins x2h, then q1H x4h, then follow MD orders.

8) What is a Stroke Bag? Located in ED pyxis medroom—consist of supplies to mix and administer t-PA, IV pump, calculator, dosage calculator sheet, manual BP cuff, timer, pt education material, downtime package.

9) Why are lipid panels and HgbA1c checked? Because pt may need statin, and pt may be diabetic or DM not well controlled

10)Avoid glucose containing solutions unless if pt is hypoglycemic. Hyperglycemia causes peri-infarct lactic acidosis, damages the penumbra and extends the infarct, worsens the outcome and decreases the t-PA efficacy

11) Pt with TIA and Afib? Should be admitted to MICU or PCU

12) What are some factors of stroke: HTN, smoking, HLD, AF, DM, OBESITY, ETOH, Illicit Drugs, Sedentary lifestyle

13) What about the CT of the head? Interpretation of a head CT by MD is completed within 15mins and documented (door-to-CT result 35mins).

14) How long do dire labs take? Dire lab tests are resulted within 35mins of pt presentation with stroke.

15) Who mixes t-PA for inpatiet stroke alerts? Inpatient pharmacy/MICU RN

16) Care for ischemic stroke pt? --explain to pt about CT, MRI, Carotid Doppler, labs, Echo --fall, aspiration or seizure precautions --ASA/Plavix order --SCD’s on dysphagia screening for 48hrs or til SLP --check orders for BP parameters

ACUTE CHANGE IN MENTAL STATUS

An acute change in mental status (AMS) is one of the highest-risk changes you can see. It can mean stroke, sepsis, hypoxia, hypoglycemia, intracranial bleed, medication toxicity, or impending ICU transfer.
First, is the patient awake? Are they protecting their airway? Are they breathing normally? Are they responding to voice or pain? If they are unresponsive or barely responsive → call for help immediately.
Check orientation + ability to follow commands. Ask: "What’s your name?" "Where are you right now?" "Squeeze my hands." "Lift both arms." You’re assessing: orientation, speech, comprehension, motor function
Get a blood sugar, Check SpO2 and RR, work of breathing, check for stroke signs, check BP, check for possible opioid overdose or med toxicity.
Call for Help If Any of These Are Present: Patient becomes unresponsive, GCS dropping, New focal neurological deficits, Severe agitation or combativeness, O₂ saturation dropping, SBP < 90 or > 180 with symptoms, Concern for stroke, Sepsis signs
Have this ready when you call MD: Latest vitals, Blood sugar, Neuro changes, Medication changes, Urine output, Recent labs
Antipicate: ABG, CBC, CMP, Lactate, Blood cultures, CT head

DANGEROUS ARRHYTHMIA

CMR Calls you and says the patient is having a dangerous arrhythmia. What do you do?
Confirm the Rhythm (5–10 seconds). Look at the tele strip. Check leads and electrodes. Then check pulse. Does the rhythm have a pulse?
The pulseless rhythms are Ventricular fibrillation (VF) and Pulseless ventricular tachycardia (VT). The perfusing but dangerous rhythms are Sustained VT, Symptomatic bradycardia, New rapid AF with instability, and Complete heart block.
Assess your patient and do a 10 second perfusion check. Check their Level of consciousness, Blood pressure, Pulse strength, Skin color/temperature, Chest pain, Shortness of breath
If the patient is: Hypotensive, Altered, Unresponsive, No pulse → Treat as an emergency
If unstable or pulseless: Call RRT or Code Blue immediately. Phrasing: "Rapid Response to room ___ — patient with ventricular tachycardia and hypotension." or "Code Blue room ___ — patient pulseless with ventricular fibrillation."
If Pulseless (VF / pulseless VT): Start ACLS immediately, Call Code Blue, Start CPR, Get defibrillator, Attach pads. Defibrillation is the treatment.
If VT with pulse but unstable.. Well first what are the signs of instability?: SBP < 90, AMS, Chest pain, Shock, Pulmonary edema. Call RRT, Apply defibrillator pads, Place patient on continuous monitoring, Start oxygen, Prepare for synchronized cardioversion
If Symptomatic Bradycardia (HR < 40–50, hypotension, syncope, altered mental status). Call RRT, Apply defib pads, Oxygen, IV access, Prepare for Atropine or transcutaneous pacing.
Think about reversible causes: Electrolytes (Low potassium, Low magnesium), Acute MI, Ischemia, Digoxin toxicity, QT-prolonging drugs, Hypoxia, Sepsis.
Do the nursing interventions that make a big difference before the team arrives: Place defibrillator pads, Bring crash cart, Ensure good IV access, Start oxygen, Obtain vitals, Print tele strip, Draw labs if ordered (K, Mg, troponin).
Dangerous arrhythmias you might have on Telemetry: 1) Ventricular Tachycardia (Wide fast rhythm >120). Call RRT if sustained. 2) Ventricular Fibrillation. Immediate code blue. 3) Complete Heart Block. AV dissociation. Often requires pacing. 4) Torsades de Pointes. Polymorphic VT. Usually due to low magnesium or prolonged QT.
Ask yourself: Does the patient have a pulse? Is the patient stable or crashing? Do I need RRT or Code Blue right now? Everything else comes after that.
Subtle Signs your patient may develop a lethal arrhythmia soon: New frequent PVCs, Runs of VT, Electrolyte abnormalities, New chest pain, QT prolongation, Sudden diaphoresis, Restlessness.
Know what arrhythmias to call an RRT for: Sustained Ventricular Tachycardia (VT) because this can turn into V Fib. New Complete Heart Block (Third-Degree AV Block) because patients can suddenly lose perfusion. Torsades de Pointes because it can turn into V Fib quickly. AF with RVR >150–160 plus symptoms because it can trigger ischemia or cardiogenic shock. Frequent runs of Ventricular Tachycardia AKA non-sustained VT as this often precedes sustained VTach or V Fib. V-Fib? Call code blue.
Know when to closely monitor: New bundle branch block with chest pain, Prolonged QT (>500 ms), Frequent PVCs (>6/min), Bigeminy or trigeminy, New bradycardia
TL;DR: Is there a pulse? Is the patient perfusing? Could this turn lethal in minutes? If the answer to #3 is yes → RRT early.

ACUTE BLEEDING

First, what patients are most likely to be bleeding? Be extra alert for post-op patients (first 24–48 hrs), patients on anticoagulants (heparin, warfarin, DOACs), GI bleed history, liver disease, recent procedures (biopsy, cath, PEG placement)
Acute bleeding can look subtle at first. Sudden vital sign changes are often the earliest clue. Look for the classic hemorrhage pattern: Tachycardia (HR rising), Falling BP or narrowing pulse pressure, Increasing RR, New O2 requirement, Decreasing urine output. Check vitals.
Look for physical signs of blood loss. Perfusion changes such as Pale or ashen skin, cool clammy skin, delayed capillary refill, weak or thready pulses, new dizziness or weakness
Patient may say: "I feel weird", "I'm really tired suddenly", "I'm lightheaded"
Check for visible bleeding, especially if patient is post-op. Check the obvious places: Surgical incision or dressing soaking through, large expanding hematoma, blood in drains (JP, Hemovac), Hematuria, Melena or bright red stool, Hematemesis, Bleeding from IV sites or central lines. Also check under the patient because sometimes they’re sitting in blood. Apply direct pressure on the bleeding if it is external. As well as reinforce dressing and elevate limb if applicable, Do not remove saturated dressings, just add more.
Look for internal bleeding clues. Watch for sudden abdominal distension, new severe abdominal or back pain, decreasing hemoglobin, restlessness or anxiety, altered mental status. Scenario: A patient on heparin or anticoagulants becomes tachycardic and pale with belly pain.
Look at Lab clues: Falling Hgb/Hct, Elevated lactate, Abnormal coags (INR/PT/PTT). But know that labs lag behind real bleeding. Vitals change first.
If acute bleeding is highly suspected or confirmed, ensure 2 large bore IV's for blood transfusion and bolus. Call RRT if you see SBP < 90, HR > 120, AMS, or Rapid deterioration.
Notify MD: "Patient appears to be actively bleeding. His HR increased from 88 to 118, BP dropped to 92/58, he's pale and dizzy, and his surgical dressing is rapidly saturating. I'm concerned about acute hemorrhage."
Anticipate STAT CBC, Type & screen / type & cross, Coags, Blood transfusion, Imaging or surgical consult.
Did you notice? It looks like a lot of symptoms of acute bleeding are similar to those in a patient experiencing septic shock (hypotension, tachycardia, weakness. So how do we differentiate? Well, sepsis patients will often also have a fever or hypothermia, as well as confused or delirious. While bleeding patients will be more dizzy or lightheaded, with a normal tempature. Acute bleeding will usually have cool clammy skin, while sepsis can have warm flushed skin. Also, pay attention to how the hemoglobin is trending. Is it falling? Ask the patient if they are having increased pain at their surgical site.

HEMODYNAMIC INSTABILITY

Your patient is experiencing hemodynamic instability

Examples of hemodynamic instability: SBP < 90 or MAP < 65, Rapid drop in BP from baseline, HR > 120 or new arrhythmia, Altered mental status, Cold, clammy skin, Weak or thready pulses, Urine output < 30 mL/hr, New chest pain, Respiratory distress, Lactate rising.
Grab vitals. Check ABCs: Is the patient protecting airway? What is the RR, work of breathing, and O2 Sats?
If the patient is on telemetry, check their rhythm strips and check for VT, AFib RVR, heart block, bradycardia. Arrhythmias are a very common cause of sudden instability.
Notify MD of findings.
If patient needs an RRT: Notify Charge RN, if Airway related also call RT, get crash cart, ensure IV Access,
How do I know to call a rapid? If SBC < 90, MAP < 65, HR > 130, new confusion, severe respiratory distress, chest pain + hypotension

BIGGEST "OH SHIT" MOMENTS

BP dropping every time you recheck, patient suddenly confused, Grey / ashen skin, Barely palpable radial pulse, Patient says "I feel like I’m going to die." Call RRT.

ACUTE HYPOTENSION / SHOCK

Your patient is experiencing acute hypotension

You would see: SBP < 90, MAP < 65, Sudden drop in BP >30 mmHg, New tachycardia with dizziness or lethargy
The common causes? Sepsis, dehydration, medication effects (opioids or antihypertensives), GI bleed, cardiogenic shock, massive PE
Your patient may look pale, sweaty, weak. "Something looks wrong". Urine output suddenly drops
1) Confirm the blood pressyre (appropriate cuff size, cycle the BP
2) Check if they are dizzy/confused, tachy, pale/cool/clammy, and if urine output is dropping. Then NOTIFY MD.
3) Call for help: PAge relief RN, Charge RN, and possibly RRT.
4) Lay pt flat (Trendelenburg is outdated.)
5) Apply oxygen even if sats look normal
6) Ensure IV Access (preferably 18-20 g)
7) Start spiking fluids.
8) If not already, place pt on telemetry, ensure pulse ox cont. w/good waveform, BP cycling every 2-3 min
9) Critical thinking: Think of the cause. Bleeding? Check surgical sites or under patient. Cardiac? Ask about chest pain and check for arrhythmias. Sepsis? Check if pt has sa known infection, fever, and increased RR. PE? Check for sudden dyspnea, tachycardia, and sudden oxygen need. Medication related? Check recent BP meds, sedatives, opioids.
10) Anticipate: Large fluid bolus, Stat labs (lactate, CBC, CMP, ABG), Blood cultures if sepsis suspected, EKG, Chest X-ray, Possibly vasopressors, ICU transfer
Signs pt will crash: BP < 80 systolic, MAP < 60, HR > 130, New confusion, Cold mottled skin, Minimal urine output, Lactate >4. These patients often need ICU within minutes to an hour.
Mental script: Symptomatic hypotension trending down. Are they perfusing? Oxygen. Lay them flat. Get fluids ready. Call RRT.

CHEST PAIN / SUSPECTED ACS

Your patient is experiencing Chest Pain / Suspected ACS

1) Check if your patient is stable. Look for these danger signs: Crushing chest pressure, Diaphoresis, Shortness of breath, Nausea/vomiting, Radiation to jaw/arm/back, New confusion, Pale/clammy skin. If they look very ill or unstable → call Rapid Response immediately.
2) OPQRST: Onset (Sudden vs. gradual), Provocation (Worse with exertion?), Quality (Pressure, squeezing, heaviness?), Radiation (Jaw, arm, back), Severeity (0-10), Time (When did it start?)
3) Immediate action: Stop patient from moving. "Please stay in bed and try not to exert yourself." Increased activity increases myocardial oxygen demand.
4) If not done already, place patient on Telemetry, Cont. Pulse ox, and BP cycling q2–3 minutes. Look at the rhythm. ST elevation, VT, New heart block, and Frequent PVCs.
5) Give oxygen (2–4 L nasal cannula) if: SpO₂ < 94%, if patient appears dyspneic
6) Obtain STAT EKG within 10 minutes of chest pain. Look for: ST elevation, ST depression, T wave inversion, new LBBB. Ensure MD sees this immediately.
7) Notify MD. Then Notify Charge RN and RRT if severe: persistent chest pain hemodynamic instability concerning EKG diaphoresis or dyspnea. Example call: "Patient with new onset chest pain 8/10 pressure radiating to left arm. BP 148/88, HR 110. Tele sinus tach. Getting a stat EKG." Notify RRT as well if SBP < 90, HR > 130, new arrhythmia, respiratory distress, syncope, ST elevation.
8) Anticipate: Nitroglycerin administration SL Q5 minutes x3, monitor BP closely during this time. Anticipate aspirin administration (this stops platelet aggregation), anticipate morphine. Anticipate STAT Troponin, CBC, CMP, BNP sometimes, Coags. Troponin is often drawn: 0 hr → 3 hr → 6 hr
Signs your patient is having a REAL MI: Crushing pressure, Radiation to arm/jaw, Diaphoresis, Nausea/vomiting, Sense of doom, New ST elevation. These patients may go to cath lab quickly.
Atypical ACS Symptoms: usually in elderly, diabetics, and women. The symptoms may be shortness of breath, fatigue, nausea, back pain, epigastric pain. With no obvious chest pain.
Basically: Chest pain? --> Check vitals, Verify Tele Rhythm, Get the EKG, Administer Nitro if ordered, and Notify provider
Reality? About 70–80% of chest pain on the floor ends up being non-cardiac (GERD, anxiety, musculoskeletal).

The 6 subtle telemetry changes nurses notice before a patient declares a heart attack.

NEW ST Depression. This is a common early ischemia sign. Often seen in NSTEMI or unstable angina. ST Segment will dip below baseline, especially during chest pain.
T-WAVE Inversion. T waves normally point upward. If they suddenly flip downward, it can signal: myocardial ischemia or reperfusion changes If a patient says "I feel weird" and you notice new T wave inversions, get an EKG.
Increasing PVCs. This is when ischemic myocardium becomes electrically irritable. You may start seeing: isolated PVCsm, couplets, runs of VT. If a patient suddenly goes from no PVCs → frequent PVCs, think: ischemia, electrolyte imbalance, or hypoxia.
New Bundle Branch Block. This can actually indicate a large anterior MI. Telemetry clue: QRS suddenly widened (>120 ms), bizarre morphology. This is something cardiology takes very seriously.
Sudden Sinus Tachycardia without explanation. Sometimes the first sign of myocardial ischemia is simply: HR jumps from 70 → 110–120. The heart is compensating for reduced perfusion.

RESPIRATORY FAILURE

Your patient is experiencing Respiratory Failure (Impending Intubation)

The goal is to recognize the signs early, maximize oxygenation, call for help, and prepare for possible intubation.
1) Assess your patient at bedside immediately. Check: Are they oxygenating and ventilating? Red flags: Severe work of breathing, Accessory muscle use, Tripoding, Unable to speak full sentences, Gasping or agonal breathing, Altered mental status, Cyanosis. If they look like this, call Rapid Response immediately.
2) Rapid assessment: RR > 30 is dangerous. Mental status: new oneset confusion indicates CO₂ retention or hypoxia. Accessory muscle use means severe distress. Are they able to speak? Only single words = severe. Skin color: check forcyanosis or gray color. Fatigue: quiet breathing after distress is bad.
3) Sit the patient fully upright in high-fowler's to maximize lung expansion. Then apply high-flow oxygen: non-rebreather at 15 L/min. Make sure that the reservoir bag is inflated, the mask fits properly, and the oxygen flowmeter is actually turned up.
4) Confirm the pulse ox is accurate. Bad waveforms are common. Check the probe placement, warm fingers, nail polish, and poor perfusion. Always correlate with the patient’s appearance.
5) Call Rapid Response / RT if the patient has: SpO₂ < 90 despite oxygen, severe work of breathing, mental status change, respiratory rate >35. Call RRT immediately. Example: "Rapid response to room 415. Patient in severe respiratory distress, satting 82% on non-rebreather."
6) Place the patient on full monitoring: Tele, Pulse Ox, BP Cycling Q 2-3 min.
7) Prepare suction. Since respiratory failure often involves secretions, mucus plugs, and aspiration. Have suction ready and working.
8) 7. Grab the Ambu bag. You may need to assist ventilation before intubation. Signs you may need to bag include decreasing consciousness, sats falling into 70s–80s, irregular breathing. RT or the code team will usually take over, but having it ready matters.
9) Anticipate: ABG, Chest XRay, Neb treatments, High-flow nasal cannula, BiPAP / CPAP, Possibly intubation
What are the common causes? Pneumonia worsening, Pulmonary edema, COPD exacerbation, Pulmonary embolism, Mucus plugging, Aspiration, Sepsis.
Subtle signs respiratory failure is coming include: RR slowly climbing, new anxiety or agitation, tachycardia, increasing oxygen requirement, restlessness, patient saying "I can’t catch my breath."
Signs intubation is imminent: SpO₂ < 85 on non-rebreather, RR > 40, severe fatigue, CO₂ retention with confusion, silent chest (minimal air movement)
A dangerous sign: when a patient who was struggling to breathe suddenly becomes quiet and lethargic, that is not improvement. It can mean respiratory muscle fatigue → impending arrest. Call RRT immediately.
Mental script: Airway. Breathing. Sit them up. Max oxygen. Call RT.

UNCONTROLLED HYPERTENSIVE CRISIS

Your patient is experiencing an Uncontrolled Hypertensive Crisis

1) First, confirm the blood pressure. Take it on both arms if possible. Recycle BP, correct cuff size, and make sure patient is not moving or talking.
Concerning numbers: SBP ≥ 180 DBP ≥ 120 But the symptoms matter more than the number.
2) Quickly assess for organ damage. This determines whether it's an emergency. How? Ask/assess for: Neurologic damage such as headache, confusion, vision changes, stroke symptoms. Cardiac such as chest pain, shortness of breath, pulmonary edema. Check for renal damage such as decreased urine and hematuria. Check if the patient is having severe anxiety and/or nausea/vomiting. If any of these are present → hypertensive emergency.
3) Immediately place the patient on telemetry if not already, and obtain 12 Lead EKG regardless if there's an order or not. Ensure cont. pulse ox, BP cycling Q2-3 minutes. You want to watch for arrhythmias and BP changes with treatment.
4) Treat pain or anxiety if present. Keep patient resting in bed and reduce activity. Stress and pain can drive BP higher.
5) Notify MD immediately. "Patient with BP 210/118 with severe headache and blurred vision. Tele sinus tach 105. No chest pain. Neuro exam intact but anxious." Expect STAT medication orders.
6) Give anti-hypertensives per order. This includes IV labetalol, IV hydralazine, IV nitroglycerin. The goal is controlled reduction, not a crash. For IV Nitro, ONLY RRT NURSE CAN GIVE THIS, the other 2 are ok for bedside RN to administer IV Push.
Important rule: BP must drop slowly, Lowering BP too fast can cause: stroke, myocardial ischemia, renal failure. Typical goal: Reduce MAP by ~10–20% in the first hour.
Watch for complications such as neurologic changes, chest pain, shortness of breath, decreasing urine output. These may indicate organ injury already happening.
Call RRT if severe hypertension occurs with: neurologic symptoms (blurry, chest pain, pulmonary edema, acute confusion, stroke signs, and aortic dissection suspicion. These patients often require ICU and IV drips.
What are the common causes? You’ll often see hypertensive crises due to missed BP medications, acute pain, anxiety/panic, kidney disease, steroid use, drug withdrawal, autonomic dysregulation.
So, what are the subtle signs hypertensive emergency is developing? Worsening headache, visual disturbances, sudden agitation, vomiting, confusion. These may signal hypertensive encephalopathy.
When BP is extremely high: Confirm the BP Look for organ damage. Put them on monitoring. Call provider. Lower BP slowly.
Reality: A BP like 190/100 without symptoms often ends up being treated with oral medications, not an emergency. But 210/120 + symptoms can become life-threatening quickly.

Common scenarios causing hypertensive crisis:

Missed medication spke (Most common): BP 180–200 systolic and patient feels fine. They missed their BP meds. Common causes: admission medication delay, NPO status, patient refusing meds. What usually happens: Provider orders something like: PO labetalol, PO hydralazine, amlodipine. These patients usually do not require RRT.
Pain/Anxiety Hypertension: Typical signs: HR elevated and patient is anxious or restless. The pain score is 7–10 and you’ll often see: BP 190/100 that drops to 150/80 after pain medication, anxiolytics, and calming environment. This pattern is very common post-op.
Hypertensive encephalopathy (Dangerous): This is true hypertensive emergency. Classic symptoms include a severe headache, confusion, vision changes, vomiting. BP is often > 200 systolic. This happens because high pressure disrupts cerebral autoregulation, causing brain swelling. These patients often require IV antihypertensive drips and ICU transfer.
Flash Pulmonary Edema: This is one of the scariest hypertensive emergencies. What it looks like: BP 220/120, severe shortness of breath, crackles, pink frothy sputum. Patients sit upright and gasping. Interventions includes: nitroglycerin, diuretics, BiPAP, ICU. These patients can deteriorate within minutes.
Aortic Dissection (Rare but Catastrophic): Classic presentation includes sudden tearing chest or back pain, BP very high, patient looks terrified. It may sometimes have unequal arm BPs, neurologic symptoms, and syncope. This is a surgical emergency. Immediate actions and RRT aggressive BP control, and CT angiography.
When BP is extremely high, ask yourself: 1) Are there symptoms? 2) Is there organ damage? 3) Does the patient look sick? Pattern recognition usually tells you the answer within seconds.
Common scenario: BP 195/100, patient eating dinner watching TV. These almost always turn out to be non-emergent hypertension. But when someone with BP 210/120 looks pale, confused, or gasping, experienced nurses immediately think: "This is a hypertensive emergency."
There’s one very subtle sign hypertensive crises that often predicts rapid deterioration and ICU transfer. This is Sudden neurologic change in a patient with very high blood pressure. Even if the change seems mild. This includes Sudden confusion, Severe headache, Blurred or double vision, Agitation, Vomiting, New lethargy, Difficulty focusing or answering questions. With BP like: 200/110 or higher. This combination is extremely concerning.
Why is that so dangerous? Because it can cause Hypertensive encephalopathy, Posterior reversible encephalopathy syndrome (PRES), Intracranial hemorrhage, Ischemic stroke. When neurologic symptoms appear, the brain may already be swelling or bleeding.
In emergency, anticipate: STAT CT head, IV antihypertensive drip, ICU monitoring.
Patterns to notice: BP climbing through the shift, Patient c/o headache, Patient becomes restless or confused, Vomiting or worsening neuro symptoms

SYNCOPE / COLLAPSE

Your patient is experiencing Syncope / Collapse

1) Prevent injury FIRST. Support the patient and guide them to the bed or floor. Call for help, activate staff assist if needed. If they’re already down: Do not yank them upright immediately
2) Immediate ABC check: Airway --> Is it open? Any vomiting or obstruction? Breathing --> Look at chest rise.Count RR quickly. Apply O2 if SpO₂ < 94% Circulation --> Palpate pulse (carotid if needed), Look at skin color (pale, gray, diaphoretic). If no pulse or abnormal breathing → CODE BLUE
3) Lay patient flat. Most syncope improves with supine positioning. Position: Flat Legs elevated slightly (if tolerated). This improves venous return to the brain.
4) Get vitals immediately. Cycle vitals fast: BP, HR, SpO₂, RR, and get a blood glucose. Always check glucose early because hypoglycemia can look identical.
5) Check respsonsiveness. Ask: "Can you hear me?" "What’s your name?" "Where are you?" Look for: delayed awakening, confusion, focal deficits. If neuro deficits → Stroke alert
6) Put them on telemetry. Common causes: Bradycardia, heart block, V-tach, A-fib RVR, Asystole pauses. If rhythm unstable → call RRT
7) Look for the cause: Vasovagal (most common). This happens often after: Standing, going to bathroom, pain, blood draw. Symptoms: pale, diaphoretic, nausea, slow HR.
8) Assess for orthostatic hypotension: "Did you just stand up?". This is common in: Elderly patient, dehydration, BP meds, and diuretics.
Other causes could be arrhythmias (esp. if pt had palpitations before syncope and tele was abnormal), hypovolemia (check for active bleeding and low HgB as well as tachycardia and hypotension), pulmonary embolism (check for chest pain, hypoxia, tachycardia, and sudden collapse)
Anticipate: EKG, Orthostatic vitals, CBC, BMP, Troponin, Telemetry monitoring, IV fluids, and sometimes CT head (if fall or neuro change)
Notify RRT if: SBP < 90, HR < 40 or > 130, New arrhythmia or O₂ requirement rising, patient not waking up, syncope with chest pain, syncope with stroke symptoms, syncope with chest pain, syncope during exertion, no pulse briefly, tele pauses or VT, persistent hypotension, patient not waking up
Questions to ask patient: "Did you feel dizzy first?" "Any chest pain?" "Any palpitations?" "Did you hit your head?". Check for head injury, pupils, and neuro status
Rapid assessment: Pulse, Skin color, Breathing, Telemetry rhythm, BP, Glucose. This identifies most dangerous causes within seconds.
Reality: Most syncope episodes end up being vasovagal or orthostatic, but we treat it seriously because occasionally it’s the first sign of arrhythmia, PE, or hemorrhage

SEIZURES

Your patient is experiencing a Seizure

Seizures can look very dramatic or extremely subtle, which is why you must learn to recognize both the obvious and the sneaky ones. The priorities are always protect the airway, prevent injury, and identify the cause. First, let's go over how to recognize a seizure.
1) Classic Generalized (Tonic-Clonic) Seizure. These are the seizures everyone recognizes. Typical signs include sudden loss of consciousness, body stiffening (tonic phase), rhythmic jerking (clonic phase), eyes rolled upward, jaw clenching, drooling or foaming, possible cyanosis, incontinence, and then post-ictal confusion or sleepiness. This usually lasts 30 sec – 2 minutes.
2) Subtle Seizures (Commonly Missed). These are easy to mistake for confusion or psych issues. Signs may include: sudden blank stare, lip smacking, chewing motions, picking at sheets, unresponsive but eyes open, sudden confusion, jerking of one arm or face, eyes deviated to one side. This is often focal seizure activity.
3) Clues it was a seizure (even if you didn’t see it). You might walk in after the event and notice: Patient very confused, extremely sleepy, tongue bite (especially side of tongue), urinary incontinence, sudden headache, muscle soreness. This is called the post-ictal phase.

Now, what do you do if your patient is seizing?

1) Stay With the patient and immediately call for help. You may activate staff assist or RRT depending on severity.
2) Protect the patient From injury: Lower bed, remove nearby objects, pad rails if available. Do NOT restrain the patient
3) Position the patient: Turn them onto their side (recovery position). This prevents: Aspiration, airway obstruction from saliva or vomit
4) Do NOT put anything in the mouth.
5) Time the seizure. This is extremely important. Tell the team: "Seizure started at ___" Most seizures stop within 1–2 minutes.
6) Check the airway and oxygen. Ensure Cont. pulse ox is on, have suction ready (Yankauer oral suction). If secretions are heavy, suction the mouth.
7) Check blood glucose: Hypoglycemia can cause seizures. Always check POC glucose.
8) Put them on monitoring, Ensure telemetry, continuous pulse ox, frequent BP, and watch for post-seizure hypoxia or arrhythmia.
9) After the seizure stops (Post-ictal Care): Common findings include confusion, sleepiness, headache, slow response. Actions: Recheck vitals, Perform neuro assessment, Ask if they have a history of seizures.
When to Call RRT Immediately: If the seizure lasts > 5 minutes, multiple seizures without recovery, airway compromise, persistent hypoxia, first-time seizure, patient not waking up. Seizure > 5 minutes = status epilepticus → emergency.
Most common causes of seizures: Metabolic: Hypoglycemia, hyponatremia, uremia. Neurologic: Stroke, brain tumor, head trauma. Alcohol withdrawal Medications: Certain antibiotics, tramadol bupropion
Anticipate: first-line medication usually Lorazepam (Ativan) IV. Other possible meds: Diazepam, Levetiracetam (Keppra), and Fosphenytoin.
Rapid assessment: Time seizure started, airway, SpO₂, glucose, type of movement, responsiveness. These details help the doctor decide what kind of seizure this was.

ANAPHYLAXIS / SEVERE ALLERGIC REACTION

Your patient is experiencing Anaphylaxis / Severe Allergic Reaction

This is one of the few situations where minutes matter. The key is recognizing it early and giving epinephrine quickly. Most deterioration happens because epinephrine is delayed.
First, how do we recognize anaphylaxis? Anaphylaxis usually occurs minutes to an hour after exposure to something like: antibiotics (penicillins, cephalosporins, vancomycin), contrast dye, blood transfusions, latex, food, and new medications.
Classic signs of anaphylaxis. Look for multiple systems involved: 1) Airway / throat: Throat tightness, hoarse voice, trouble swallowing, tongue or lip swelling, stridor. 2) Breathing: Wheezing, shortness of breath, chest tightness, hypoxia. 3) Skin: Hives (urticaria), flushing, itching, facial swelling. 4) Circulation: Hypotension, tachycardia, dizziness, syncope 5) GI: Nausea, vomiting, abdominal cramping.
The scariest sign is throat swelling or stridor.

IMMEDIATE ACTIONS

1) Stop the trigger immediately. If something is infusing: Stop the medication, stop blood transfusion, clamp the line. Leave IV access in place.
2) Call for Help. Activate Rapid Response Team and tell them “Possible anaphylaxis.”
3) Prioritize airway and oxygen. Apply high-flow oxygen and watch closely for: Stridor, drooling, increasing respiratory distress. If airway swelling progresses, the patient may need urgent intubation. Have suction and ambu bag ready.
4) Give epinephrine. Epinephrine IM is the first-line treatment. Typical adult dose: 0.3–0.5 mg IM. Inject into lateral thigh. This reverses, bronchospasm, hypotension, airway swelling. Epinephrine is the life-saving drug in anaphylaxis.
5) Position the patient. If hypotensive: Lay them flat, elevate legs. If severe respiratory distress: High Fowler’s
6) Start IV Fluids. Patients often become profoundly vasodilated. Typical orders: Normal saline bolus
7) Prepare additional medications. Doctors often order antihistamines like Diphenhydramine (Benadryl), Steroids like Methylprednisolone (Solu-Medrol), and Bronchodilators such as Albuterol neb. These do not replace epinephrine. They are supportive.
8) Monitor closely. Place patient on telemetry per order, continuous pulse ox, frequent BP cycling. Watch for worsening hypotension, worsening airway swelling, respiratory failure.
Signs the patient is about to crash: Hoarse or muffled voice, stridor, rapid facial/tongue swelling, SBP dropping, severe wheezing, agitation or confusion, cyanosis. These patients may require intubation quickly.

POST-OP DETERIORATION

Your patient is experiencing Post-Procedure Deterioration

Post-procedure deterioration happens especially after things like biopsies, cath lab procedures, thoracentesis, paracentesis, endoscopy, surgery, or sedation. The key is recognizing early signs something went wrong and escalating quickly. The approach is basically: ABCs → vitals → look for the specific complication tied to that procedure.
Most post-procedure complications show up within the first few hours. Common early clues include Sudden tachycardia, new hypotension, increasing pain, shortness of breath, bleeding from site, altered mental status, new oxygen requirement, rapid swelling near the procedure site. Or if a patient suddenly says “I don’t feel right” after a procedure, immediately reassess.
1) Do a quick ABC assessment. 1) Airway: Talking normally? Stridor? 2) Breathing: Respiratory distress, Chest rise, SpO2. 3) Circulation: Skin color, Pulse quality, Bleeding.
2) Get full vitals immediately. Cycle BP frequently if unstable. Sudden changes often indicate internal bleeding, pneumothorax, sedation complications, and shock
3) Inspect the procedure site. Look for bleeding, rapid swelling, expanding hematoma, drain output changes. Examples include cath site bleeding, surgical site hemorrhage, neck hematoma after thyroid procedures.
4) Assess pain carefully. Sudden severe pain after a procedure is a red flag. Chest pain could mean PE or pneumothorax, abdominal pain could indicate bleeding or perforation, back pain could indicate retroperitoneal bleed, and severe headache could be a post-LP complication.
5) Check oxygenation. Apply oxygen if needed. Watch for: New hypoxia, increased work of breathing, diminished breath sounds. Example: After thoracentesis, worsening SOB could mean pneumothorax.
6) Put the patient on monitoring: Telemetry, Continuous pulse ox. Watch for arrhythmias, hypoxia, and BP instability
Call RRT if you see: SBP < 90, HR > 120, new oxygen requirement, significant bleeding, severe pain, mental status change. Early escalation is expected.

Common post-procedure complications:

Bleeding / Hemorrhage: Tachycardia, Falling BP, Pale/clammy skin, Increasing pain, Falling hemoglobin
Pneumothorax: This happens often after thoracentesis, lung biopsy, or central line placement. Symptoms are sudden SOB, hypoxia, chest pain, and diminished breath sounds
Sedation complications: Especially after endoscopy, colonoscopy, and IR procedures. Signs include hypoventilation, low RR, decreased consciousness.
Internal perforation: happens after colonoscopy, endoscopy, abdominal procedures. Signs include severe abdominal pain, distention, fever, peritonitis
MD usually orders: CBC (check for bleeding), BMP, Chest X-ray, CT scan, ABG, IV fluids. This is based on the symptoms.
Rapid post-op assessment: 1) Mental status 2) Skin color 3) Breathing 4) Procedure site 5) Vitals
Reality: the two procedures that most commonly cause sudden deterioration are actually: Thoracentesis and Cardiac catheterization because they can cause pneumothorax or internal bleeding, and those patients can crash surprisingly fast.