BLS & CPR

Pathophysiology Instruction
Done for clients who go into cardiac arrest If NO caregivers are around to help, you must
meaning the heart has stopped pumping! initiate immediate CPR with high quality
compressions. Start chest compressions BEFORE
calling for help if you are the only caregiver!
CARDIAC ARREST (Most students get this wrong on exams)

Causes
Immediate CPR with
Caused by a variety of factors from Hypoxia, high quality compressions
respiratory failure, toxins, blood clots, electrolyte
imbalances & others. They are commonly
described as Hs & Ts.

#1

Hypoxia Respiratory failure Toxins

Immediate CPR with chest compressions helps to

Cl - Cl -

Cl -
+ -
provide IMMEDIATE oxygen or perfusion to the
Na+

Na+ Na+

Blood clots Electrolyte imbalances

brain & vital organs in order to prevent damage
& even DEATH!

Adult CPR
2 2

During CPR, compressions are

min min

Chest compressions Immediately paused every 2 mins to assess

pulse.
KEY Numbers 10 seconds

Rate is 100 - 120/min NCLEX TIP

Depth of at least
NCLEX TIP How to SHOCK an Adult
2 - 2.4 inches (5 - 6 cm) AED pads (8 years & older)
Hands in center of chest lower half 1. Defibrillator pads are placed
Upper right chest near
of sternum
the shoulder 2. Call out & look to make sure
Breaths: everyone is clear
Left lateral chest near
Manual: 30 compressions the anterior axillary line 3. Continue chest compressions
& 2 rescue breaths below the nipple immediately after the shock
Intubation: Every 6 seconds
without interruption

Upper right chest

0 00:00:00

AED
₂
O

00:06
LOWER HALF
OF STERNUM
NO IV sedation needed.
Left lateral chest
NO synchronized button.
That is for cardioversion
 BLS & CPR II

Pediatric AED Infant CPR

1. Brachial pulse for 10 seconds

How to SHOCK a Child or less NCLEX TIP
Key terms
1 AED pad on the chest & Place a roll under
2. Call for help to activate an
1 on the back the shoulders
emergency response
DO NOT overlap or touch Slightly extended neck
3. 2 Minutes of CPR
pads
100 - 120 compressions
per minute TECHNIQUE 1

MEMORY TRICK Single Rescuer 30:2 NCLEX TIP

Two Rescuers 15:2

4. Retrieve an AED after 2 minutes STERNUM

of CPR (single rescuer)

TECHNIQUE 2

STERNUM
PRIORITY
Asystole Treatment
₂
O

1. High Quality CPR Priority

2. Epinephrine every 3 - 5 minutes
Kaplan Question
3. Intubate & Ventilate
5

Which artery does the nurse

min
EPINEPHRINE

4. Treat the causes Cl -

Cl -

+ -
Cl -

Na+

use to assess the pulse rate of

Na+ Na+

an infant client during cardio-

pulmonary resuscitation?
Side Note
Brachial artery Brachial artery

NO shocking ASYSTOLE

Asystole (flat line) NCLEX TIP

PEA (pulseless electrical

activity)
Post-resuscitation Care
PEA
(pulseless electrical activity)

CPR with Pregnancy

Key terms

Comatose/
NCLEX TIP not following commands
Chest compressions slightly higher Priority intervention:
on the sternum - Cold fluids for
Uterus: manually displaced to therapeutic hypothermia
6 hours
left side or place a rolled blanket
under right side
NOT SUPINE

NCLEX TIP
Priority, if circulation does not return after 4 minutes then
an immediate C-section must take place typically within C #1 PRIORITY
C
5 minutes of starting CPR
COMATOSE COLD FLUIDS
not following Commands therapeutic hypothermia
PRIORITY

4
mins

5 mins
Burns

Types & Causes Care for Minor Burns

Burn injuries caused by direct tissue damage C C C
from exposure to: Cool water Cover the area Clothing removal
• Sun
• Chemicals
• Thermal (boiling liquids)
• Electricity

Prehospital Care
ANTIBIOTIC

C - Cool water
OINTMENT

� Briefly soak area

As you know the skin is made of 3 layers - • NO ice, creams, antibiotic
ointment to open skin
epidermis, dermis, & subcutaneous tissue
!

!
!

(that fatty bubble looking tissue) C - Cover area “Clean dry cloth” HCP remove anything

under the skin we find fascia, muscle, & bone.

sticking to the skin

C - Clothing & Jewelry removal

• Not adhered
Epidermis

Dermis Saunders
The nurse instructs firefighters
Subcutaneous tissue that in the event of a tar burn,
which is the immediate action?
• Cooling the injury with water

First-degree (superficial) Chemical burn injury... The nurse

REMOVING ALL
• Dry with blanchable redness instructs the employees that
what is the first consideration in
Second-degree (partial thickness) immediate care?
• Painful Blisters NCLEX TIP • Removing all clothing,
! including gloves, shoes,
• “Red, moist, shiny fluid filled vesicles” and any undergarments

Third-degree (full-thickness)
!
• Dry waxy white, leathery, or charred Kaplan Question
black color, non-blanchable
The nurse is caring for a client
Fourth-degree (full-thickness) with full thickness burns
covering 20% of their body.
What is the priority of care
after ensuring a patent airway:
! ! ! ! !
! !
! ! !
!
● IV fluids
! ! ! !

Notes
Major Burns

Pathophysiology
Saunders
Massive tissue damage & cellular destruction leads to
widespread systemic inflammation that increases vascular Extensive burn injury ... 45% of
total body surface area… 45%
permeability (leaky blood vessels that fill up the body like a
planning for fluid resuscitation, !
water balloon). This results in low fluid volume within the the nurse should consider that
blood vessels leading to Hypovolemic Shock & then death! fluid shifting to the interstitial !
!
spaces is greatest during which
Low fluid volume
time period?
18 - 24 hours
! • Between 18 and 24 hours
after the injury
!
!

Signs & Symptoms

First 24-hours Over 5.0

Saunders
HEMATOCRIT
K
High Potassium (Hyperkalemia)
Severe burn injury that
Over 5.0
covers 35% of the total 60% (0.60)
� Potassium Priority Pumps heart
� HIGH Potassium = HIGH Pumps body surface area (TBSA).
� Tall, Peaked T Waves on ECG The nurse is most likely to
NCLEX TIP
note which finding on the
Fluids FLOW - electrolytes GO!!!
Low Sodium (hyponatremia) HEMOGLOBIN HEMATOCRIT
laboratory report?
Below 135 NCLEX TIP 12-18 normal 36-54% normal

!
• Hematocrit 60% (0.60)
Elevated H/H
� Hemoglobin: 12 - 18 normal
! Na
!
� Hematocrit: 36 - 54% normal

Treatments 1 2 3
≥ 30 mL/hr
90
KEY Term
LACTATED RINGER’S 0.9%
Sodium Chloride
250 mL

#1 Intervention first 24-hours

IV Lactated Ringer’s (LR) solution
IV Normal Saline Saunders
A client is undergoing fluid
replacement after being burned
on 20% of her body 12-hours LACTATED RINGER’S

PRIORITY ago… blood pressure is 90/50, a

pulse rate of 110, and a urine
IV Lactated Ringer’s IV Normal Saline output of 20 mL over the past
(LR) solution (0.9% sodium Chloride) hour. The nurse ... anticipates
which prescription?
Increasing IV Lactated
LACTATED RINGER’S Ringer’s solution

NaCl 0.9%

#1

Administer enteral feedings ≥ 30 mL/hr

Once bowel sounds return

Kaplan Question
Assessment of ≥ 90 Systolic

Fluid Resuscitation
1. Urine output
30 mL/hr or MORE
2. Blood pressure
(90/systolic Or MORE)
3. Heart rate less than 120/min.
≥ 30 mL/hr
90 Patient with burns who is
immunocompromised….
NCLEX TIP What precautions should be
taken to prevent ... infection?
Avoid placing fresh
< 120/min flowers or plants in or
near the client’s room
 Burns - Rule of 9s
& Rehabilitation Phase

Rule of 9s Rehabilitation Phase

The Rule of 9s is used to quickly estimate the Happens after the wounds fully heal & typically
percentage of the body affected by a burn, called takes around 12 months or so depending on the
Total Body Surface Area (TBSA). Used in order to severity of the burn.
calculate the necessary fluid resuscitation needed.

RULE OF NINES
4½% 4½%
4½%

Don’t let
4.5% anterior 9% 9%

THE NCLEX TRICK YOU

4½%

4½%
4½%

4½%

4.5% posterior
9% 9%

1%

9% 9% 9% 9% 9%

Key point
Infection is NOT a big risk

W W
RULE OF NINES
4½% 4½%

4.5% front 9% 9%
4½%

4½%

4½%

4½%

4.5% back 9% 9%

1%

9% 9% 9% 9% 9%

W W
WATER-BASED LOTION HELPS Wear PRESSURE GARMENTS
RULE OF NINES
4½% 4½%

9% front
Water based
9% 9% LOTION
4½%

4½%

4½%

4½%

9% back 9% 9%

1%

18% 9% 9% 9% 9%

RULE OF NINES
Patient Education NCLEX TIPs
4½% 4½%

W - Water-based lotion helps

1%
9% 9%
4½%

4½%

4½%

4½%

9% 9%

1%

For the perineum

9% 9% 9% 9%
W - Wear pressure garments
E - Exercise daily
(Range-of-motion)
Once the total body surface area is calculated
then the volume needed for emergency fluid
resuscitation within the FIRST 24 hours can be
calculated using the Parkland Formula

Parkland Formula
40.0
0
4 mL x kg of body weight x TBSA %

4 mL body weight %TBSA

Burns
Top Missed Questions

Top MISSED Questions

Client has full thickness burns to 4½ %

all posterior body surfaces.

Using the rule of nines, calculate
9%

4½ %

4½
%
the % of total body surface area
9%
4.5% + 18% + 9% + 18%
= 49.5% TBSA
affected.
Posterior body surfaces:
9% 9%

Head = 4.5%
Back = 18%
Right & left arm = 9% 50% of the body
Right & left leg = 18%

Answer = 49.5% TBSA

Client has partial thickness

burns to the anterior legs &
perineum.
Using the rule of nines, calculate
the % of total body surface area
4½%
affected.
9% 1% peri-area
18% right & left leg
4½%

4½%

9%
1% + 18%
1%

= 19% TBSA

Answer = 19% TBSA

9% 9%

.00
100

Client weighed 100 kg with 19%

TBSA… calculate the lactated 4 mL 100 kg 19% TBSA
Ringer’s fluid resuscitation
needed? 3,800 mL 3,800 mL

4 mL x 100 kg x 19 TBSA
LACTATED RINGER’S LACTATED RINGER’S

Answer = 7,600 ml
(within the first 24 hours)

8 hours 16 hours
9 ECG Strips on the NCLEX

1. Normal sinus rhythm

Treatment:
None - continue to monitor

Causes:
Being healthy

Memory tricks

Normal beat - evenly spaced

2. Bradycardia

Treatment:
BRADY Bunch Atropine ONLY if symptomatic
old TV show (slow times)
showing low perfusion (pale,
cool, clammy)
<60 Causes: ATROPINE

Vagal maneuver (bearing down),

Memory tricks
meds (CCB, Beta Blockers)
BRADYcardia
Below 60/min

3. Ventricular Fibrillation (V Fib)

Treatment:
1. V Fib - Defib #1 Defibrillation
immediately Stop CPR
to do it & before drugs!
*NO synchronization needed
2. Drugs: LAP - Lidocaine, L A P
Amiodarone, Procainamide
Causes:
Memory tricks Untreated V Tach, Post MI, LIDOCAINE
AMIODARONE
PROCAINAMIDE

E+ imbalance, proarrhythmic meds

Fib is flopping- squiggly line

4. Ventricular Tachycardia (V Tach) Memory tricks

Causes:
Post MI, Hypoxia,
Low potassium, Low magnesium
C
Treatment: C - Count a pulse
C - Cardiovert
1. Early Defibrillation! NCLEX TIP *Synchronize First
Apply defibrillator pads & Sedation
Call out & look for everyone to be

D
CLEAR!
Shock & IMMEDIATELY continue
chest compressions
Memory tricks D - Dead - NO PULSE
2. When to Shock? NCLEX TIP
D - DEFIB!!
V Tach with No pulse = Defibrillation
V Tach Tombstone pattern
*NO Synchronize
V Tach with Pulse = Cardioversion D - Don't wait
9 ECG Strips on the NCLEX II

5. Atrial Fibrillation (A Fib) Digoxin

Causes:
Valvular disease, Heart failure, Pulm. HTN,
COPD, after heart surg. A T
Treatment:
Max 2.0
1. Cardioversion (after TTE to rule out clots)
*Push Synch 60
2. Digoxin - Deep Contraction
Check ATP Before giving: 40 kg

A - Apical pulse 60
T - Toxicity (Max 2.0 range) visual disturbances,
N/V, Anorexia P
P - Potassium below 3.5 - HIGHER risk for
Memory tricks toxicity
< 3.5
3. Anticoagulants: Warfarin (monitor INR, Vit.
No P wave = Fibrillation FloPPing K antidote, moderate green leafy veggies)
Potassium

K+

6. Atrial Flutter (A Flutter) Causes:

Valvular disease, Heart failure, Pulm. HTN,
COPD, after heart surg.
Treatment:
DIGOXIN

1. Cardioversion (after TTE to rule out clots)

*Push Synch
2. Digoxin - Deep Contraction
Max 2.0
Check ATP Before giving: 60
A - Apical pulse 60 40 kg

T - Toxicity (Max 2.0 range) visual disturbances,

N/V, Anorexia < 3.5
K
P - Potassium below 3.5 - HIGHER risk for
Memory tricks
Potasssium

toxicity
3. Anticoagulants: Warfarin (monitor INR, Vit.
K+
A FluTTer = sawTooTh K antidote, moderate green leafy veggies)

7. SVT - Supraventricular Tachycardia KAPLAN

Which medication should be held 48-hours
Causes: prior to an elective cardioversion for SVT?
Stimulants, Strenuous exercise, hypoxia, Digoxin due to increased ventricular
irritability
heart disease
Client with SVT has the following
Treatment: assessment data: HR 200, BP 78/40, RR 30

1. Vagal Maneuver (bear down like Priority action: Synchronized

cardioversion
having a bowel movement, ice cold
stimulation)
PRIORITY
2. Adenosine - RAPID PUSH & flush
Memory tricks with NS - HR may stop
3. Cardioversion - *Push Synch
Super Fast = Supraventricular

8. Torsades de Pointes Memory tricks

M
Magnesium

Causes: Magnesium

Post MI, Hypoxia, Low magnesium Mg+

Treatment:
Magnesium Sulfate NCLEX TIP
M
Mellows out the heart
Memory tricks

Tornado Pointes
9 ECG Strips on the NCLEX III

9. Asystole - Flatline

Epinephrine, Atropine & CPR

*NO Defibrillation
(NO shock) NCLEX TIP

Memory tricks
Assist Fully! … patient is flatlined

R R
NCLEX Key Terms
PP P

Q Q
S S

1. P wave = Atrial rhythm 4. “Bizarre” - Tachycardia

3.
Asystole

2. QRS wave - Ventricular rhythm Question:

Ventricular Tachycardia

Question: “Bizarre rhythm with wide QRS complex”

Answer: Ventricular Tachycardia
“Lack of QRS complexes”
R

Q
Answer: Asystole 5. “Sawtooth” - Atrial Flutter
“Wide bizarre QRS complexes”
S

3.
Answer: V Tach
V Tach

3. “Chaotic or unorganized” - Fibrillation

Question:
A FluTTer = sawTooTh

“Chaotic rhythm with no P waves”

Answer: Atrial Fibrillation
Atrial Flutter

“CHAOTIC rhythm without QRS complexes”

Answer: Ventricular Fibrillation
Atrial Fibrillation

If you know these, you will pass the NCLEX! NCLEX TIP

Normal sinus rhythm Bradycardia Ventricular Fibrillation (V Fib)

Ventricular Tachycardia (V Tach) Atrial Fibrillation (A Fib) Atrial Flutter (A Flutter)

3.

SVT - Supraventricular Tachycardia Torsades de Pointes Asystole - flatline

5 Step
EKG INTERPRETATION

Heart rate Rhythm P wave PR interval QRS

(in seconds) (in seconds)
60 -100/min Regular Present before 0.10 - 0.20 Normal shape
each QRS, identical (<5 small squares) < 0.12
P/QRS ratio 1:1

Heart Rate
8 x 10 = 80
1. Normal Sinus Rhythm
1 2 3 4 5 6 7 8
Rate - 60 -100
count the peaks - we have 8 here
multiply by 10 = 80 beats!

Rhythm

2. Rhythm - R peaks are evenly spaced apart. R R-R int. R R R R R R

To quickly measure this simply grab some

paper & mark 2 R peaks then just march it out.
The R peaks should be even every time.

P Wave
R R

3. P wave - which is our atria contracting -

is it present? & does it have its buddy QRS?
we need a P with QRS every time P T P T

Q Q
S S

PR interval (in seconds)

R

4. PR interval - basically measures the 0.2 sec

time it takes between atrial contractions

0.5 mV
5 mm

& ventricular contractions should be 5 mini P

boxes or less - or .10 - 2.0 seconds here. PR int.

QRS (in seconds) R-R int.

0.2 sec

5. QRS - Ventricles contracting

0.5 mV
5 mm

PR ST
seg. seg.

Is it present, upright & TIGHT? P T

Should NOT be wide, should only be PR int. Q ST int.

3 boxes - .12 seconds here.

S
QRS
int.
QT int.
 Atropine
Symptomatic Bradycardia

Drug name: Memory tricks Side Note

AtroPINE ATROPINE

Symptomatic bradycardia
ATROPINE

If drugs do not work to fix the problem, then we

Indication: have to put the patient on external pacing:
Given to speed up a slow heart rate with

Key word 1st 2ⁿd

Correct sequence:
1. Atropine
Symptomatic ATROPINE
2. External pacing

bradycardia

MOA:
Atropine acts to increase the heart rate by blocking the
action of the vagus nerve to block the PNS (parasympathetic
Signs: Symptomatic bradycardia nervous system) REST & DIGEST, and turns ON the SNS
?
? (fight & flight) in the heart like flicking a light switch.
Mental status changes
?
? ?
?
1. Confusion
2. Irritability
3. Agitation
SNS
ATROPINE

PNS
Parasympathetic nervous system

Key points
Atropine is effective when we see normal sinus
rhythm and reversal of the symptoms. They will
show you normal sinus rhythm like this & no
more hypoxic symptoms, like confusion, agitation,
hypotension or syncope.
Common NCLEX Question
Atropine for a client with a heart rate of 38,
bp of 88/65, reports confusion and dizziness.
Which ECG strip would show medication
effectiveness?

1. 60-100
Normal Sinus rhythm R peak x 10
and reversal of the symptoms 2.
8 x 10 = 80

3.

ATROPINE

4. CORRECT
 Adenosine

Drug name: MEMORY TRICK Indication:

1st line drug to treat
- supraventricular tachycardia
AdenoSINE
Puts the HR Down 150 beats/min
in a DEN with aDENosine

MOA: SUPRAventricular tachycardia

SUPER tachy heart rate

It works by slowing impulse conduction through the AV

node to slow down the heart rate. Therefore can work too
well & stop the heart all together - so SAFETY is the main
concern.
KEY Points

SVT ORDER of treatment

1. Vasovagal maneuver FIRST!
BEFORE adenosine (bearing down
1 2
like having a BOWEL MOVEMENT)

Common TEST Question 2. Adenosine IV push “rapidly over 1-2

seconds” followed by a saline flush
Which drug does the nurse 3. Cardioversion to Convert the heart
anticipate the provider will order? rhythm - “Push the SYNCHRO-
SYNC

Adenosine #1 NIZE BUTTON” for Cardioversion

SYNC

Don’t let
THE NCLEX TRICK YOU
CARDIOVERSION DEFIBRILLATION

Cardioversion Defibrillation
C - Cardioversion D - Defibrillation - if you
C - Count a pulse D - Don't have a pulse
C - Controlled Rhythms D - Deadly rhythms (VFib & Vtach no pulse)
Synchronized button & sedation D - Don't Synch (shock away!)
PULSE NO PULSE

SYNC
SYNC

SYNC
Antidysrhythmics I
Cardiac Pharmacology

Class Drug Name Mainly for Image of ECG Strip

Class 1 Procainamide V Tach &
Sodium-channel blockers & Lidocaine V Fib

Class 2 Propranolol Atrial Fibrillation

Beta blockers Atrial Flutter
HTN (hypertension)

Class 3 Amiodarone V Tach &

Potassium-channel blockers V Fib

Class 4 Verapamil Atrial Fibrillation

Calcium-channel blockers Diltiazem Atrial Flutter
Nifedipine HTN (hypertension)

Others Adenosine SVT

Digoxin A Fib
(cardiac glycoside)
Atropine Symptomatic
(anticholinergic) Bradycardia

Top Missed Question

Key Points Which drugs do we teach slow

position changes due to
orthostatic hypotension?
Select all that apply.
Dizziness
1. Atenolol
Teach SLOW position changes 2. Atropine ?
3. Amiodarone
4. Amlodipine
5. Digoxin
NORMAL
HIGH
LOW

Hypotension - must reassess the BP every hour

NORMAL

6. Diltiazem
HIGH
LOW

When BP is LOW - we got to go SLOW! 7. Furosemide

MEMORY TRICK
Think ABCD start on TOP of the heart affecting atrial rhythms.
Think LAP like in your lap, since these drugs affect ventricular rhythms.

Drug Name Indication & Key Terms:

Drug Name Indication & Key Terms:
Atropine Symptomatic Bradycardia
A Lidocaine V Tach & V Fib
L
Adenosine SVT (supraventricular tachycardia)
SE: Low BP, Low Platelets
Beta Blockers Hypertension, SVT, Tachycardia,

B “Propranolol” A fib & A flutter

SE: LoL = Low BP, Low HR, bronchospasm
SA node
Amiodarone V Tach & V Fib

A
AV node

SE: Low BP, Low HR,

C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Pulmonary TOXICITY!!!
“Verapamil” “Diltiazem” A fib & A flutter
SE: Low BP, Low HR, dizziness

P
Procainamide V Tach
SE: Low BP, Low Platelets
D
Digoxin A fib & Heart Failure
SE: Toxicity (NV, Vision changes)
 Antidysrhythmics II
ABCDs - Atrial Rhythm drugs
Cardiac Pharmacology

MEMORY TRICK Notes

A
B SA node
Think ABCD, start on the
TOP of the heart affecting C AV node
atrial rhythms affecting
the SA or AV node
D L
A
P

Drug Name Indication & Key Terms: TOP MISSED Test Question
A Atropine Symptomatic Bradycardia Atropine for a client with a heart rate of 38,
bp of 88/65, reports confusion and dizziness.
Which ECG strip would show medication
effectiveness?
Puts the heart rate really HIGH like on TOP of “a PINE” tree for
60-100
atroPINE. 1.

Given for: ‘’Symptomatic Bradycardia’’ below 60 BPM with signs 8 x 10 = 80

of low oxygenation like mental status changes (confusion, 2.
Evenly Spaced
altered, agitation) or pale blue skin signs. Goal is to get back to
NORMAL sinus rhythm! 3.

<60
0₂

0₂
0₂
0₂ 4. CORRECT

Drug Name Indication & Key Terms: 1 2

A
KEY Points

Adenosine SVT (supraventricular tachycardia)

1. Give it FAST = IV push in
1-2 seconds NCLEX TIP
2. Saline Flush immediately AFTER
DEcreases the heart rate, like putting it into a DEN (for foxes) or
Downstairs.
Given for:
SVT - Supraventricular Tachycardia
* Key points:
Know how this rhythm looks! SVT = Super Fast!
Give it FAST = IV push in 2 seconds followed by flush
Super Fast = SVT

Drug Name Indication & Key Terms:

B Beta Blockers
“Propranolol”
Hypertension, SVT, Tachycardia,
A fib & A flutter
SE: LoL = Low BP, Low HR
Common Question
What drug is causing this rhythm?

Propranolol
Beta blockers end in “-LOL”
Memory trick: Lower the 2 L’s - Low HR & Low BP
Given for: <60
Hypertension & to put the brakes on fast rhythms like SVT, tachycardia, A fib, & A flutter. 5 x 10 = 50
Side Effects: 1 2 3 4 5
• B - Bradycardia (HR below 60 BPM) & low BP
• B - Bronchospasm (avoid asthma & COPD)
• B - Blood glucose masking s/s of low sugar
• B - Bad for clients in end stage heart failure
* Orthostatic hypotension (dizziness upon standing) - teach slow position changes!
Antidysrhythmics IV
LAP - Ventricular Rhythm Drugs
Cardiac Pharmacology

L Lidocaine
SA node
Think LAP like in your lap,
A Amiodarone AV node since these drugs affect
ventricular rhythms
L

P Procainamide A
P

Mainly give for those deadly ventricular rhythms:

• Ventricular Fibrillation (V Fib) LOW cardiac OUTput
Vfib LOW oxygen OUT to the body
• Ventricular Tachycardia (V Tach)

Memory Trick:
Vtach
Any rhythm starting with a V = VERRRY deadly.

Since the ventricles are responsible for all the Cardiac OUTPUT
0₂
meaning OXYGEN rich blood OUT TO the body, so low Cardiac OUTput
means Low oxygen OUT to the body.

Lidocaine
“Cain” Calms the ventricles. Priority
L Lidocaine Given for:
V tach, & V fib mainly, but also can work for
Key Point SVT, A fib, & A flutter.
LIDOCAINE
HYPOtension
Lidocaine Toxicity
GLASGOW COMA SCALE
EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
1st
Neuro checks are a PRIORITY

Amiodarone Side Effects

A Amiodarone Typically given 2nd if Lidocaine does not
Neg. Chronotropic = Less beats
work. This is because of its life-threatening
Key Point
TOXIC effects!
<60

Pulmonary toxicity Memory trick

“dry cough & dyspnea”
“difficulty breathing while Neg. Dromo = Less Electrical impulse
ambulating”
“shortness of breath”
AMIODARONE

P Procainamide
ESTED
NLY T
T COMMO
NO

‘’Cain’’ calms those ventricles just like Lidocaine but this drug PROCAINAMIDE

is becoming less & less popular in the hospital setting &

therefore not commonly tested.
Vasopressors
Alpha & Beta Physiology
Cardiac Pharmacology

VasoPRESSors - PRESS on the vessels

VasoPRESSors - PRESS on the blood vessels,
Goes back to the heart
Main Vasopressors
increasing blood pressure in order to squeeze
• Epinephrine
• Norepinephrine
oxygen rich blood back to the CORE of the body
• Vasopressin to perfuse the vital organs (sort of like
• Dobutamine squeezing a toothpaste bottle).
• Dopamine

Indication
Key Receptors: Alpha & Betas
Increase BP Cardiac Arrest Shock Mode of Action
NORMAL

They work by activating

HIGH
LOW
NORMAL

NORMAL
HIGH
LOW

Alpha & Beta receptors

HIGH
LOW

ACLS
Dobutamine
inside the heart & blood
vessels
Norepinephrine
EPINEPHRINE
EPINEPHRINE

Vasopressin

Alpha 1 - Constriction of Vessels

Alpha 1 - Anaconda (memory trick)
• Squeezing down the blood vessels so blood is pushed back to the heart.

Alpha Agonist
• Think AGonists ADD to the BP to increase it (example: vasopressors)
Alpha Antagonists
• Are ANTI constriction - less constriction = less pressure to lower BP (example: clonidine)

Beta 1 = 1 Heart
Beta Agonists - think AGonists ADD - Faster heart rate. (example: Vasopressors)
• Positive Chronotropic (chronos = time) more beats per minute.
• Positive INOtropic = more FORCEFUL beats, which increased Cardiac OUTPUT (increased
blood coming OUT of the heart to perfuse the body)

Beta Antagonists - are ANTI heart, used to decrease the HR & BP (example: beta blockers) NORMAL

• Negative Chronotropic - Less Beats

HIGH
LOW

• Negative Inotropic - Less force

Beta 2 = 2 Lungs Indication Alpha 1 Beta 1 Beta 2

Beta 2 Agonist Anaconda 1 heart 2 Lungs & Dilation
• Think they ADD to the lungs - dilating Constriction • Chrono - High HR
• Inotropic - C.O.
Big Lungs
& Vessels
both the vessels & bronchi - like a big
BIG
Septic shock &
balloon or beach ball Epinephrine Cardiac arrest
Medium Small

(example: Vasopressors & Albuterol)

Norepinephrine Septic shock BIG Medium Small

Vasopressin
Desmopressin
Hypovolemic shock - - -
Dopamine Cardiogenic shock Med.
BIG Small

Dobutamine Cardiogenic shock Small BIG Medium

Vasopressors
Top Tested Drugs
Cardiac Pharmacology

Epinephrine & Norepinephrine Kaplan Question

1st line drug Epinephrine
Epinephrine treatment is effective if ….
(Brand: Adrenaline) Answer: BP 130/67,
Apical HR 99, Cap refill
Norepinephrine HESI Question less than 2 seconds
(Brand: Levophed)
Epinephrine Less than 2s
Key difference
Initiates heart contraction

EPINEPHRINE
EPINEPHRINE
Epinephrine

Adrenaline
Cardiac Arrest during cardiac arrest
130/67 HR 99
• Asystole
• PEA (pulseless electrical Activity)
NORMAL

Vasopressin & Desmopressin (ADH)
Vasopressin
Vasopressin - synthetic ADH
(AntiDiuretic Hormone)
• ADH - Adds Da H20
Pressin - PRESSes that BP UP
HIGH
LOW
DI - Diabetes Insipidus
Indication DI - end up DIuresing or DraIning a lot of fluid
Given for Diabetes Insipidus (DI)
where clients Drain a lot of fluid!
ADH is given to “Add Da H20” to
the body, adding fluid volume &
not affecting the constriction of
vessels.

Dobutamine & Dopamine

Indication
INOtropic
D’s for DEEP Contraction Given to treat cardiogenic shock - “INcreased cardiac contractility”
DEEP contraction Dopamine & Dobutamine
where the heart FAILS to pump! “INcreased forceful contraction”
These guys give a DEEPER heart
Dobutamine
DOPAMINE contraction, to increase that blood
out of the heart & to the body
(increasing cardiac output & BP)

HESI Question Kaplan Question

Dopamine Dopamine
Activates alpha 1 and beta 1 receptors Given for a patient with
hypotension, what indicates
Therapeutic Effects: effectiveness?
• Low doses act on dopamine
receptors 1 1 Answer: Increased cardiac output
• Moderate doses acts on beta 1
receptors
• High doses acts on alpha 1 and
ATI Question
beta 1 receptors
Dobutamine, Dopamine
Assess IV site hourly for s/s infiltration • Assess BP hourly
• Monitor vital signs

Notes
Inotropic, Chronotropic,
Dromotropic

D D D INOtropic
Digoxin Dopamine Dobutamine “INcreased cardiac contractility”
“INcreased forceful contraction”
3 Ds for DEEP contraction
Digoxin
DOPAMINE Dobutamine D - Digoxin
2.0 +
D - Dopamine
D - Dobutamine

Chronos
Clock
HR<60 Neg. Chronos - Neg time
Positive Chronos - Positive time
Faster HR - Positive Chronotropic
Lower HR - Negative Chronotropic

Dromo
Drums
Neg. Dromotropic -
stable heart rhythm

Inotropic Chronotropic Dromotropic

Drug Force of Heartbeat Rate of Heartbeat Rhythm of Heartbeat

A amiodarone + Pos. - Neg. - Neg.

B beta blockers
Atenolol - Neg. - Neg. - Neg.
C calcium CB - Neg. - Neg. - Neg.
C cardiac glycosides
+ Pos. - Neg. - Neg.
Digoxin

D dobutamine + Pos. X X
D dopamine + Pos. + Pos. X
E epinephrine + Pos. + Pos. X
Antidysrhythmics III
ABCDs - Atrial Rhythm Drugs
Cardiac Pharmacology

Drug Name Indication & Key Terms:

C C
C Ca Channel Blockers
“Verapamil” “Diltiazem”
Hypertension, SVT, Tachycardia,
A fib & A flutter
Calcium Contracts the muscles

Calcium

Ca
Since calcium contracts the muscles, when calcium is blocked with CCBs,
it calms the heart
Memory Trick: CCBs lower the Couple heart vitals: HR & BP
Given for:
Hypertension, tachycardia, SVT, A Fib, & A Flutter
Side Effects:
Orthostatic hypotension (dizziness upon standing) - teach slow position changes

3 Common Questions
Q1: Intended EFFECT for Q2: Priority adverse effect Q3: Most important patient
Diltiazem? to watch for when giving teaching when giving
Amlodipine? Verapamil?
Ventricular rate decreased Dizziness Slow position changes
from 160 to 70s
Q1: Intended EFFECT for Q2: Priority adverse effect
Diltiazem? KEY WORD
to watch for when giving
Q2: Priority adverse effect Q3: Most important patient Amlodipine?
to watch for when giving teaching when giving Slow position changes
Amlodipine? Verapamil? Ventricular rate decreased Dizziness

Dizziness
160 70 beats/min Slow position changes
from 160 to 70s

Diltiazem

Drug Name Indication & Key Terms: D is for DEEP Contraction

D Digoxin A fib & Heart Failure
SE: Toxicity (NV, Vision changes)
DIGOXIN DEEP contraction

Digoxin Digoxin
Is a TOXIN so monitor levels - under 2.0 is SAFE.
It DIGs for a deeper heart contraction to help the heart contract more
forcefully & decreases the heart rate (NOT Blood pressure), so no need
for slow position changes

Main Side Effect = Toxicity Key Sign Common NCLEX Question

Max Range 2.0 Report "dizziness & lightheaded" Q1: A client on digoxin is having difficulty
1st signs of toxicity: reading a book or some type of vision
Anorexia Bradycardia problem
Nausea / Vomiting
Vision changes (difficulty reading)

Max 2.0 what is the key lab value to monitor?

Digoxin
Creatinine! Over 1.3 = bad kidney
Hypothermia

Pathophysiology

Occurs when core body temp is less than 95oF (35oC).

The body basically becomes like a popsicle with all the
organs freezing over & shutting down being unable to
compensate for heat loss! The nearly frozen heart muscles
(myocardium) become very irritated leading to DEADLY Ventricular Fibrillation (V Fib)
cardiac arrhythmias like Ventricular Fibrillation (V Fib).

Priority action: NCLEX TIP #1 #2

1. Attach cardiac monitor

2. Anticipate defibrillation

Signs & Symptoms

Everything is super cold & nearly frozen here!

Heart:
- Pulses are weak and thready from the cold heart muscles
Lungs:
- Wheezing may be heard indicating bronchospasms
- Crackles at bases of lungs indicating pulmonary edema
from fluid buildup!

Interventions

NCLEX TIP
1st 2 nd Airway: Anticipate Mechanical Ventilation
Circulation: Attach the cardiac monitor
(anticipate defibrillation)
Rewarming Process:
Airway Breathing Circulation Passive methods
Active internal warming
Warmed IV fluids via 2 large bore IVs
Cover with warm blankets (head & trunk)

1st
2 nd
Frostbite

Pathophysiology

Tissue in the body basically freezes like a popsicle

resulting in ice crystal formation within the cells of the body!
Ice crystal formation

It’s like every cell becomes a little snowball.

There will be Vasoconstriction as the vessels contract
from the cold, leading to decreased blood flow
- vascular stasis.

Signs & Symptoms

Superficial frostbite:
Skin blue, mottled, or waxy yellow
Deep frostbite:
Skin white, hard → Gangrene

Treatment

Rewarming PRIORITY NCLEX TIP

Warm water soaks (whirlpool)
Elevate affected extremity after
rewarming
Provide analgesic pain meds
NO pressure to the site
NO heavy clothing, blankets
NO massaging, rubbing
NO occlusive dressings on wounds
NCLEX TIP
 Shock

Memory trick
Pathophysiology S S

Shock is a critical condition 0₂ 0₂ NORMAL

Shock Severely low 0₂ 0₂
blood pressure
where the body has decreased 0₂

HIGH
0₂ 0₂

LOW
0₂ 0₂

0₂
0₂
tissue perfusion eventually
leading to organ failure and
NORMAL

HIGH
LOW
death

4 Stages of Shock
1 2
I. Initial II. Compensatory
5 TYPES OF SHOCK
3 4
III. Progressive IV. Irreversible 1. Septic shock
Septic shock caused by widespread Sepsis Septic shock

bloodborne infection - think Sepsis

I. Initial infection causes Septic shock

There is too little oxygen in the blood Anaerobic metabolism

to feed the organs, resulting in 2. Neurogenic shock

anaerobic metabolism, meaning
0₂
0₂
0₂

metabolism without oxygen - Neurogenic shock caused by spinal

Blood glucose
T-6
BUT s/s are absent in this stage cord injury T-6 or higher.

II. Compensatory
3. Hypovolemic shock (hemorrhagic)
The body is trying to compensate for the LOW oxygen,
So the heart will pump faster (tachycardia) & RR Hypovolemic shock (hemorrhagic) caused by blood
increases to get more oxygen (tachypnea) body loss like from a trauma or a gunshot wound or even
compensates with the sympathetic nervous system from surgery or burns
to speed up the vital signs & renin-angiotensin
activation to maintain BP and oxygenation to keep the
organs perfused

III. Progressive
Key sign 4. Cardiogenic shock
Cold and clammy skin Cardiogenic shock where the heart fails to pump like
PRIORITY NCLEX TIP in heart failure exacerbation or an MI heart attack
heart muscles are weak & fail to pump

IV. Irreversible
5. Anaphylactic shock
Death is imminent
Anaphylactic shock from a severe allergic reaction like
from a bee sting, eating seafood or something you
have an allergy to
Septic Shock

Pathophysiology
Septic shock Pathophysiology results from a septic widespread
bloodborne infection that overwhelms the body typically caused
by a bacterial infection like Pneumonia - infection in the lungs or
even UTI or kidney infection that gets worse. A systemic cytokine
release inside the bloodstream causes extreme vasodilation & fluid

Lorem
leakage from capillaries

Signs & Symptoms Memory trick

S S
Severely low blood pressure Severely low
Shock 0₂ 0₂
blood pressure
0₂ 0₂
0₂

0₂
0₂
NORMAL
NORMAL

HIGH
LOW
HIGH
LOW

Low blood pressure

(Less than 80/systolic)
Cold, clammy skin
(pale & cool extremities)
Delayed capillary refill ?
?
?
? ?
Mental Status change NCLEX TIP ?

Confusion ?

Disorientation
High WBC (over 10,000) <96oF

Temp. High or very low (96°F)

NCLEX TIP
>10,000

Treatment

Emergency treatment may include supplemental

oxygen, intravenous fluids, antibiotics, and
other medications.
Neurogenic Shock

Pathophysiology

The Autonomic nervous system is damaged resulting in the blockage Spinal Cord Injury
of the sympathetic nervous system which is supposed to speed up
(T-6 or higher) NCLEX TIP
the vitals & vasoconstriction. Only the parasympathetic system is
intact - which puts the breaks on the vitals causing widespread
vasodilation & hypotension naturally, we see low & slow vital signs
like low heart rate & low BP as Vasodilation occurs making it difficult
for blood to return BACK to the heart. This decreased blood flow
BACK to the heart leads to decreased blood flow OUT of the heart
basically decreased cardiac OUTput - meaning less oxygenated blood
OUT of the heart to the body & this leads to poor tissue perfusion
T-6
from the lack of oxygen & impaired cell metabolism resulting in organ
failure & death.

Signs & Symptoms Interventions

Bradycardia NCLEX TIP PRIORITY

NORMAL

IV Normal Saline

HIGH
LOW
●
P P (0.9% sodium chloride)
PNS Parasympathetic Puts the breaks Increases the blood pressure
on the vitals
<60
PNS

PNS

SIDE NOTE
● Spinal cord injury ABOVE T-6
Autonomic dysreflexia T-6

Saunders
A client is admitted to the hospital with Triggered by a full bladder, constipation, or tight
a diagnosis of neurogenic shock after a
traumatic motor vehicle collision.
fitting clothes - anything with constriction thus
Which manifestation best characterizes place Foley in spinal trauma patients to keep the
this diagnosis?
bladder empty and offer laxatives & loose clothes
Bradycardia can save a client with a spinal cord injury
ABOVE T-6

<60

NCLEX TIPS
Low HR (bradycardia) Less than 60
Low BP (hypotension) Less than 80/systolic
Skin: Warm, Pink, & Dry
 Hypovolemic Shock

Pathophysiology

Caused by anything that can lower blood volume - Think HYPO

- LOW blood or fluid volume from excessive fluid volume loss
through diarrhea, vomiting, or fluid shifts as in burn patients
& from bleeding (hemorrhage) from trauma like a gunshot or
knife injury, or even surgery & GI bleed. HYPOvolemic shock
LOW blood volume
Signs & Symptoms
III. Progressive
Key Point
1. Hypotension (less than 80/systolic)

Hypovolemic shock - As mentioned before - 2. Tachycardia

3. Low central venous pressure
this is often seen in the progressive stage & is (normal 2-6 mmHg)
an indication that the client is GETTING WORSE!
So you must notify the healthcare provider
<80/systolic
Cold and clammy skin immediately & get some IV normal saline
PRIORITY NCLEX TIP started quickly! NORMAL

HIGH
LOW
KAPLAN Saunders
A client in shock develops a central
Which vital sign would alert the nurse venous pressure (CVP) of less than 2 1
st

to potential hemorrhage following a mm Hg. Which prescribed intervention

nephrectomy: should the nurse implement first?

HR 110
110 Increase the rate of intravenous
IV fluids

Interventions
Norepinephrine Norepinephrine
MAP >65 mmHG
88%

NORMAL
HIGH
LOW

PRIORITY = Hemodynamic stability

CRITICAL! DO NOT delay a new
1. LOWER head of bed right
bag of norepinephrine NCLEX TIP
away NCLEX TIP
NEVER place the HOB in MAP (mean arterial pressure) SpO2 = the sensor should be
High Fowler’s position Over 65 mmHg placed on the forehead instead
2. IV Normal Saline CVP (central venous pressure) of extremities
(0.9% sodium chloride) 2 - 6 mm Hg
3. IV norepinephrine / dopamine
2-6 mmHG
Memory trick
1
st

Put the Head LOW in

2
nd

HYPOvolemic (hypotension)

NORMAL
HIGH
LOW
Cardiogenic &
Anaphylactic Shock

Pathophysiology Signs & Symptoms

Cardiogenic shock Saunders
The heart fails to pump blood out of the heart & to A client having a… myocardial infarction
the body like in a heart attack where heart muscles based on elevated troponin levels … the
nurse should alert the primary health
die or heart failure exacerbation - where the heart care provider because the vital sign
fails to pump C C
changes … are most consistent with
which complication? Refer to the exhibit.
CARDIOgenic shock CARDIAC fails Cardiogenic shock

Cardiogenic shock - Cardiac problem - Heart attack - MI heart

tissue DIES - heart FAILS to pump adequately. So just look at
the BLOOD Pressure here, when clicking on the exhibit the low
blood pressure goes lower & lower!

Treatment Client’s Chart

Positive INOtropic = more FORCEFUL beats Time 11:00 a.m. 11:15 a.m. 11:30 a.m. 11:45 a.m.

Pulse 92 beats/min 96 beats/min 104 beats/min 118 beats/min

Dopamine

Digoxin
Resp. rate 24 breaths/min 26 breaths/min 28 breaths/min 32 breaths/min

BP 140/88 mm Hg 128/82 mm Hg 104/68 mm Hg 88/58 mm Hg

Dopamine & Digoxin both have INOtropic

properties meaning they help the heart to Saunders
pump more forcefully.
Client with heart failure exacerbation…
and suspected state of shock. The nurse
knows which intervention is the priority
for this client?
D - Dopamine (vasopressor) Administration of Digoxin

Caution:
Tachycardia Ds is for DEEP Contraction
(over 100/min) NCLEX TIP DIGOXIN DEEP contraction

Arrhythmias
D - Digoxin Digoxin

Anaphylactic Shock Treatment

Severe allergic reaction - like from a
bee sting or peanut allergy.
NCLEX TIP
Anaphylactic shock - severe ALLERGIC reaction

Epinephrine
EPINEPHRINE
EPINEPHRINE
Adrenaline

EpiPen Auto Injector

EKG Quick view
9 strips to know for the Nclex

Normal sinus rhythm

Bradycardia

Ventricular Fibrillation (V Fib)

Ventricular Tachycardia (V Tach)

Atrial Fibrillation (A Fib)

Atrial Flutter (A Flutter)

SVT - Supraventricular Tachycardia

Torsades de Pointes

Asystole - flatline
Heart Sounds &
5 EKG Lead Placement

Memory Trick
APETM
Heart Sounds
“All Pigs Eat Too Much”
AORTIC PULMONIC
A - Aortic (2nd Intercostal Space
(2 Intercostal Space
nd
P - Pulmonic L Sternal Border)
R Sternal Border)
E - Erb’s point
T - Tricuspid
M - Mitral
TRICUSPID
(3nd or 4th Intercostal Space
L Sternal Border)

ERB’S POINT
(3rd Intercostal Space MITRAL
L Sternal Border) (5th Intercostal Space
Midclavicular Line)

5 EKG Lead Placement

QRS Complex

R
Memory Trick
P PR Segment ST Segment T White on Right
Smoke over Fire
Brown in the Middle
PR Interval
Grass under sky (white)
Q
S
QT Interval

Proper 12-Lead Placement for Left Side of Chest

v1 4th intercostal space to the right of the sternum

v2 4th intercostal space to the left of the sternum

v3 directly between the leads V2 & V4

v4 5th intercostal space at midclavicular line

v1 v2 v
3
v5 level with V4 at left anterior axillary line v4R v6
v4 v5

v6 level with V5 at left midaxilary line

(directly under the midpoint of the armpit)
v4R 5th intercostal space, right midclavicular line