NLE Emergency & Critical Care Nursing — Basic & Advanced Life Support (CPR/ACLS)Revision Notes

Exam Tips

• NLE items often describe a scenario and ask 'what is the nurse's FIRST action' — the answer is always: ensure scene safety, then check responsiveness.
• Remember: agonal gasping = NO breathing = START CPR.
• The Chain of Survival links are commonly asked in sequence — memorize all five in order.
• Post-arrest care (5th link) is increasingly tested: targets include normoxia (not hyperoxia), normal CO2, targeted temperature management.

Key Points

• The Chain of Survival is a conceptual framework that describes the sequence of actions needed to maximize survival from cardiac arrest.
• It has FIVE links: (1) Early recognition and activation of emergency response, (2) Early high-quality CPR, (3) Rapid defibrillation, (4) Effective advanced care (ACLS), and (5) Integrated post-cardiac arrest care.
• A weak link anywhere in the chain lowers survival — this is why nurses must be competent at every link.
• The two links most directly under the nurse's immediate control are: early recognition and early, high-quality compressions.
• In the Philippine healthcare context, activating the emergency response means calling the hospital code team (Code Blue), dialing emergency services, or activating the in-hospital emergency response system.
• Survival from ventricular fibrillation decreases by approximately 7 to 10 percent for every minute without defibrillation — time is literally brain and heart tissue.

Definitions

Section Title

The Chain of Survival

Common Mistakes

• Waiting too long to confirm unresponsiveness before activating emergency response — every second counts.
• Mistaking agonal gasping for normal breathing and NOT starting CPR.
• Activating emergency response BEFORE beginning compressions when alone — the correct sequence is: shout for help/call, then immediately start CPR (or use a phone on speaker mode while compressing).
• Thinking the Chain of Survival only applies in the hospital — bystander CPR in the community (barangay level) is equally critical.

Exam Tips

• The NLE will ask the sequence — always C-A-B for adults.
• 10 seconds is the maximum time for combined pulse and breathing check — memorize this number.
• If a patient has a pulse but is not breathing: rescue breathing only, NOT full CPR.
• Scene safety is ALWAYS the first step — if an NLE question lists it as an option, it is usually the first correct answer.

Key Points

• Modern BLS follows the C-A-B sequence: Compressions → Airway → Breathing. This replaced the old A-B-C sequence because compressions circulate the existing oxygenated blood already present in the body at the time of arrest.
• Step 1: Ensure scene safety before approaching the patient.
• Step 2: Check responsiveness — tap the shoulders firmly and shout 'Are you okay?'
• Step 3: Simultaneously assess for breathing (look for chest rise) AND check the carotid pulse for NO MORE THAN 10 SECONDS. Do not take more than 10 seconds for this combined assessment.
• Step 4: If unresponsive, not breathing normally (or only gasping), and no pulse — activate the emergency response system AND get an AED/defibrillator.
• Step 5: If alone, use a mobile phone on speaker to call for help while you begin compressions.
• Step 6: Begin chest compressions IMMEDIATELY — this is the priority.
• For healthcare providers: Check the carotid pulse in adults, brachial pulse in infants.
• If a pulse is present but no normal breathing: provide rescue breathing at 1 breath every 5 to 6 seconds (10 to 12 breaths/min) and recheck pulse every 2 minutes.

Definitions

Section Title

Basic Life Support: The C-A-B Sequence and Assessment

Common Mistakes

• Starting with airway instead of compressions — the sequence is C-A-B, not A-B-C.
• Spending more than 10 seconds assessing breathing and pulse — this delays life-saving compressions.
• Checking the radial pulse instead of the carotid pulse in adults — in low perfusion states, peripheral pulses may be absent even with a heartbeat.
• Not calling for help before starting CPR when alone — you must activate emergency response (even by phone) before or immediately as you begin.

Formulas

Exam Tips

• The numbers 100-120 (rate), 5-6 cm (adult depth), 30:2 and 15:2 (ratios), and 2 minutes (switch interval) are all high-yield NLE numbers — memorize all of them.
• Pediatric two-rescuer ratio = 15:2. Adult two-rescuer = 30:2. This distinction is a classic NLE trap.
• With an advanced airway: continuous compressions + 1 breath every 6 seconds. No more 30:2 pausing.
• Infant depth is about 4 cm; child depth is about 5 cm. Both are 'one-third of AP chest diameter.'

Key Points

• High-quality compressions are the single most important determinant of survival from cardiac arrest.
• RATE: 100 to 120 compressions per minute. Too slow (below 100) gives inadequate cardiac output. Too fast (above 120) reduces depth and prevents adequate cardiac refilling between compressions.
• DEPTH (Adult): At least 5 cm (2 inches) and not more than 6 cm (2.4 inches). Shallow compressions do not generate adequate blood flow; excessive depth causes rib and sternal fractures.
• DEPTH (Child): Approximately one-third of the anteroposterior (AP) chest diameter, which equals approximately 5 cm.
• DEPTH (Infant): Approximately one-third of the AP chest diameter, which equals approximately 4 cm.
• FULL CHEST RECOIL: Allow the chest to fully return to its resting position after each compression. Leaning on the chest ('incomplete recoil') prevents the heart from refilling with blood between compressions.
• HAND POSITION (Adult/Child): Heel of one hand placed on the lower half of the sternum (NOT on the xiphoid process), with the other hand on top, fingers interlaced.
• INFANT TECHNIQUE: Two-finger technique (single rescuer) — place 2 fingers on the center of the chest, just below the nipple line. Two-thumb encircling technique (two rescuers) — wrap both hands around the infant's chest with thumbs side by side on the sternum.
• COMPRESSION-TO-VENTILATION RATIO: 30:2 for single rescuer in ALL ages; 30:2 for two rescuers in ADULTS; 15:2 for two rescuers in CHILDREN and INFANTS.
• MINIMIZE INTERRUPTIONS: The chest compression fraction (CCF) should be at least 60 percent of resuscitation time. Pause only for rhythm analysis, shock delivery, and ventilation cycles.
• SWITCH COMPRESSORS: Every 2 minutes (or sooner if fatigued) to maintain quality. Fatigue causes significant decline in compression rate and depth within 2 minutes, often unrecognized by the compressor.
• With an advanced airway in place: deliver continuous compressions at 100 to 120/min with 1 breath every 6 seconds (10 breaths/min) — do NOT pause compressions for ventilation.

Definitions

Section Title

High-Quality Chest Compressions — The Core of BLS

Common Mistakes

• Compressing too fast (above 120/min) — reduces depth because the rescuer cannot push deep enough at very high rates.
• Using the 30:2 ratio for two-rescuer pediatric CPR — the correct ratio for two rescuers with a child or infant is 15:2.
• Compressing on the xiphoid process — correct position is the LOWER HALF of the STERNUM.
• Not allowing full recoil — leaning between compressions is a very common and harmful error.
• Forgetting to switch compressors every 2 minutes — fatigue silently degrades quality.
• Using abdominal thrusts instead of compressions on infants — abdominal thrusts are NEVER used in infants.

Formulas

Exam Tips

• Jaw-thrust = trauma/suspected spinal injury. Head-tilt/chin-lift = standard (no trauma).
• One breath every 6 seconds with advanced airway = 10 breaths/minute. This number is frequently tested.
• Just enough to see chest rise = correct ventilation volume. Avoid large, forceful breaths.
• Mouth-to-mouth-and-nose is used for infants — covers both the mouth and nose.

Key Points

• After the first cycle of 30 compressions, open the airway using the HEAD-TILT/CHIN-LIFT maneuver (standard technique for non-trauma patients).
• Use the JAW-THRUST maneuver if spinal injury is suspected — do NOT hyperextend the neck.
• Deliver 2 rescue breaths, each over approximately 1 second, with just enough volume to produce VISIBLE CHEST RISE.
• Avoid over-ventilation: excessive volume or force causes gastric inflation (risk of aspiration), raises intrathoracic pressure, and reduces venous return to the heart.
• If the first breath does not produce chest rise: reposition the airway (check head-tilt/chin-lift) and try again once. Then move on — do not keep attempting breaths at the expense of compressions.
• Advanced airway devices (endotracheal tube, supraglottic airway such as laryngeal mask airway): once inserted, deliver CONTINUOUS compressions at 100-120/min while giving 1 breath every 6 seconds (10 breaths/min). Do NOT pause compressions for ventilation.
• Ventilation rate with advanced airway: 10 breaths per minute (1 breath every 6 seconds).
• For infants: the head should be in a NEUTRAL or SNIFFING position, NOT hyperextended — hyperextension can actually close the airway in infants.
• Mouth-to-mouth for adults; mouth-to-mouth-and-nose for infants and small children.
• Barrier devices (pocket mask, bag-valve mask): preferred in healthcare settings. A bag-valve mask requires a proper seal and correct hand technique (EC clamp) to deliver effective breaths.

Definitions

Section Title

Airway Management and Rescue Breathing

Common Mistakes

• Using head-tilt/chin-lift in a trauma patient — use jaw-thrust instead.
• Giving breaths too forcefully or too fast — causes gastric inflation and reduces cardiac output.
• Pausing compressions for each ventilation when an advanced airway is in place — once intubated, compressions are CONTINUOUS.
• Hyperextending an infant's neck — neutral/sniffing position is correct for infants.

Exam Tips

• After ANY shock: IMMEDIATELY resume compressions for 2 minutes. No pulse check first.
• Transdermal patches must be removed before pad placement — common NLE scenario question.
• If pads would touch on a small child: use anterior-posterior placement.
• AED uses UNSYNCHRONIZED cardioversion (defibrillation). Synchronized cardioversion is used for unstable patients with a pulse (SVT, AF, flutter, VT with pulse) — do not confuse these.
• The 7-10% per minute survival decrease without defibrillation is a high-yield statistic.

Key Points

• Defibrillation is the DEFINITIVE treatment for ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT).
• Survival decreases by approximately 7 to 10 percent per minute without defibrillation — apply the AED as soon as it arrives.
• AED APPLICATION SEQUENCE: (1) Power on → (2) Attach pads to bare, dry chest → (3) Stop compressions, ensure no one is touching the patient → (4) Allow AED to analyze rhythm → (5) If shock advised, CLEAR the patient (verbally and visually confirm no contact) → (6) Deliver shock → (7) IMMEDIATELY RESUME COMPRESSIONS for 2 minutes before next rhythm analysis.
• PAD PLACEMENT: One pad below the right clavicle (right sternal border, below the clavicle). One pad on the left lower lateral chest (left axilla area, V4-V6 position).
• ANTERIOR-POSTERIOR placement: Used when pads would overlap (e.g., small child, or adult with inadequate chest space). One pad on the anterior chest (sternum) and one on the posterior chest (upper back).
• CRITICAL: Do NOT check for a pulse immediately after delivering a shock. Resume compressions immediately for 2 full minutes, then analyze rhythm.
• If the AED says 'No shock advised' (indicating asystole or PEA): immediately resume compressions — do NOT pause.
• SPECIAL SITUATIONS: Remove transdermal medication patches (e.g., nitroglycerin, nicotine) and wipe the site before pad placement. Place pads at least 2.5 cm (1 inch) away from an implanted pacemaker or ICD. Dry a wet chest before placing pads. For children/infants: use pediatric pads with attenuator if available (reduces energy to child-appropriate dose). If pediatric pads unavailable, use adult pads placed in anterior-posterior position so they do not touch each other.
• AEDs are safe and effective even for lay bystanders — they provide clear voice instructions and will not deliver a shock unless a shockable rhythm is detected.
• Pediatric AED dose considerations: pediatric attenuator pads deliver a lower energy dose appropriate for children.

Definitions

Section Title

Automated External Defibrillator (AED) Use

Common Mistakes

• Pausing to check the pulse immediately after delivering a shock — always resume compressions first for 2 minutes.
• Leaving a transdermal patch under the AED pad — can cause arcing, burns, and ineffective defibrillation.
• Placing pads on a wet chest — moisture conducts electricity across the skin surface, reducing the energy delivered to the heart.
• Using pediatric pads/attenuator for an adult — reduces energy to insufficient levels.
• Allowing team members to remain in contact with the patient during rhythm analysis or shock delivery.
• Placing pads directly over an implanted pacemaker — place at least 2.5 cm (1 inch) away.

Formulas

Exam Tips

• The shockable vs. non-shockable distinction is THE most important ACLS branch point on NLE.
• VF + pVT = SHOCK FIRST. Asystole + PEA = NEVER SHOCK.
• Epinephrine 1 mg every 3-5 minutes is used in ALL arrest rhythms but at different timing.
• Amiodarone 300 mg then 150 mg = only for refractory VF/pVT (after multiple shocks without ROSC).
• ETCO2 suddenly rising during CPR is a strong early sign of ROSC — stop and check for pulse.
• Post-ROSC: target normoxia (NOT hyperoxia) and normal PaCO2. Avoid SpO2 >99%.

Key Points

• ACLS builds on uninterrupted high-quality BLS by adding rhythm interpretation, advanced airways, intravenous/intraosseous (IV/IO) access, medications, and treatment of reversible causes.
• The core ACLS decision: Is the rhythm SHOCKABLE or NON-SHOCKABLE?
• SHOCKABLE RHYTHMS: Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (pVT). → Treatment: DEFIBRILLATE + CPR + Epinephrine + Amiodarone.
• NON-SHOCKABLE RHYTHMS: Asystole and Pulseless Electrical Activity (PEA). → Treatment: CPR + Epinephrine + Treat reversible causes. DO NOT shock.
• EPINEPHRINE FOR CARDIAC ARREST: 1 mg IV/IO every 3 to 5 minutes. Concentration used is 1:10,000 (1 mg in 10 mL). This vasopressor increases coronary and cerebral perfusion pressure during CPR.
• In SHOCKABLE rhythms: Epinephrine is given AFTER the second shock (not immediately at the start). In NON-SHOCKABLE rhythms: Epinephrine is given as EARLY as possible.
• AMIODARONE for VF/pVT refractory to defibrillation: FIRST dose 300 mg IV/IO bolus; SECOND dose 150 mg IV/IO. Given as an antiarrhythmic when VF/pVT persists after multiple shocks.
• LIDOCAINE: An acceptable alternative to amiodarone for VF/pVT. Doses: 1 to 1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg for subsequent doses.
• ASYSTOLE must be confirmed in MORE THAN ONE LEAD to rule out fine VF or a lead connection problem — a single flat line could be a technical artifact.
• PEA: Organized electrical activity on the monitor (looks like a rhythm) but NO palpable pulse. Most often caused by a reversible condition (Hs and Ts). Never shocked.
• ROSC (Return of Spontaneous Circulation): Signs include a sudden sustained rise in end-tidal CO2 (ETCO2), palpable pulse, blood pressure reading, spontaneous movements or breathing.
• Post-ROSC care: Target normoxia (SpO2 94-99%), normal PaCO2, mean arterial pressure (MAP) ≥65 mmHg, targeted temperature management (TTM) if indicated, identify and treat the precipitating cause.

Definitions

Section Title

ACLS: Shockable vs. Non-Shockable Rhythms

Common Mistakes

• Shocking asystole or PEA — these are NON-SHOCKABLE. Shocking a flat line is harmful and wastes time.
• Confusing epinephrine 1:10,000 (arrest, IV/IO) with 1:1,000 (anaphylaxis, IM) — this is one of the most dangerous drug errors in emergency nursing.
• Giving epinephrine for shockable rhythm immediately (like non-shockable) — in VF/pVT, epinephrine is given AFTER the second shock.
• Giving amiodarone as the first drug in any arrest — epinephrine comes first; amiodarone is for VF/pVT refractory to multiple shocks.
• Confusing PEA with a normal rhythm — PEA has an organized electrical activity on monitor but NO pulse. Always confirm with pulse check.
• Diagnosing asystole from a single lead — always confirm in more than one lead.

Exam Tips

• NLE scenario: PEA arrest in a trauma patient → think HYPOVOLEMIA and TENSION PNEUMOTHORAX first.
• NLE scenario: PEA with history of renal failure → think HYPERKALEMIA.
• NLE scenario: arrest after surgery or chest trauma → think TAMPONADE.
• Beck's Triad (hypotension + distended neck veins + muffled heart sounds) = cardiac tamponade. Memorize this combination.
• Needle decompression for tension pneumothorax: 2nd intercostal space, midclavicular line, superior border of the rib (to avoid the neurovascular bundle running under the inferior edge).

Key Points

• Every cardiac arrest — especially PEA and asystole — demands a systematic search for REVERSIBLE causes that can be treated to achieve ROSC.
• The Hs and Ts is the internationally standardized mnemonic for reversible causes of cardiac arrest.
• THE 5 Hs: Hypovolemia, Hypoxia, Hydrogen ion excess (Acidosis), Hypo-/Hyperkalemia, Hypothermia.
• THE 5 Ts: Tension pneumothorax, Tamponade (cardiac), Toxins (drug overdose/poisoning), Thrombosis pulmonary (pulmonary embolism), Thrombosis coronary (acute MI).
• HYPOVOLEMIA: Most common cause of PEA in trauma. Treatment: rapid IV/IO fluid replacement, stop bleeding.
• HYPOXIA: Ensure adequate ventilation and oxygenation. Check tube placement, suction airway.
• HYDROGEN ION (ACIDOSIS): Consider sodium bicarbonate in prolonged arrest or known metabolic acidosis/hyperkalemia.
• HYPOKALEMIA/HYPERKALEMIA: Both cause fatal dysrhythmias. Hyperkalemia treated with calcium chloride, sodium bicarbonate, insulin-glucose. Hypokalemia treated with potassium replacement.
• HYPOTHERMIA: Rewarm the patient. Do not terminate resuscitation until the patient is warm.
• TENSION PNEUMOTHORAX: Clinical diagnosis (absent breath sounds, tracheal deviation, hypotension, distended neck veins). Treatment: immediate needle decompression (2nd intercostal space, midclavicular line) followed by chest tube.
• CARDIAC TAMPONADE: Beck's Triad (hypotension, distended neck veins, muffled heart sounds). Treatment: pericardiocentesis.
• TOXINS: Antidote if available (naloxone for opioids, atropine/pralidoxime for organophosphates). Consider activated charcoal, supportive care.
• PULMONARY EMBOLISM: Consider thrombolytics during CPR if PE is strongly suspected.
• CORONARY THROMBOSIS (AMI): STEMI is a common cause of VF. After ROSC, early coronary angiography and PCI are indicated.
• In Philippine emergency settings, hypovolemia, hypoxia, and toxins (especially organophosphate poisoning from agricultural settings) are particularly common clinical scenarios.

Definitions

Section Title

Reversible Causes: The Hs and Ts

Common Mistakes

• Not thinking about the Hs and Ts during a PEA arrest — PEA is almost always caused by a reversible condition.
• Omitting one of the Hs or Ts — memorize all 10.
• Confusing the treatment for tension pneumothorax (needle decompression at 2nd ICS MCL) with tamponade (pericardiocentesis).
• Forgetting that hypothermia patients should NOT be declared dead until they are rewarmed — 'Not dead until warm and dead.'

Exam Tips

• Infant choking = 5 back slaps + 5 chest thrusts. NO abdominal thrusts. Ever.
• Pregnant or obese = chest thrusts instead of abdominal thrusts.
• Mild obstruction = encourage coughing. Do not interfere.
• If victim becomes unresponsive: begin CPR (compressions first), check mouth before each breath — VISIBLE objects only, no blind sweep.
• NLE frequently presents a choking scenario with an infant — make sure to distinguish from adult management.

Key Points

• Choking severity determines the intervention. ALWAYS assess severity FIRST before acting.
• MILD OBSTRUCTION (Partial): The person CAN cough forcefully, speak, or wheeze. Encourage continued coughing — do NOT perform abdominal thrusts. Coughing is the most effective way to expel a foreign body.
• SEVERE OBSTRUCTION (Complete): The person CANNOT speak, cough, or breathe effectively; may clutch the throat (universal choking sign); will become cyanotic. REQUIRES IMMEDIATE INTERVENTION.
• RESPONSIVE ADULT or CHILD (over 1 year of age) with SEVERE obstruction: Perform ABDOMINAL THRUSTS (Heimlich maneuver) — stand behind the victim, make a fist with one hand, place it above the navel and below the xiphoid, cover with the other hand, deliver quick inward-and-upward thrusts. Repeat until object is expelled or the victim becomes unresponsive.
• PREGNANT or OBESE victim: Use CHEST THRUSTS instead of abdominal thrusts — hands positioned on the CENTER of the sternum (same as CPR hand position).
• RESPONSIVE INFANT (under 1 year of age) with SEVERE obstruction: DO NOT perform abdominal thrusts. Alternate 5 BACK SLAPS (firm slaps between shoulder blades with heel of hand, infant held face-down) and 5 CHEST THRUSTS (2 fingers on center of sternum, infant held face-up). Repeat cycle until object expelled or infant becomes unresponsive.
• IF THE VICTIM BECOMES UNRESPONSIVE (any age): Lower the victim to the ground carefully. Activate emergency response. BEGIN CPR STARTING WITH COMPRESSIONS (C-A-B).
• CRITICAL RULE: Each time you open the airway to give a breath during CPR on a choking victim, LOOK IN THE MOUTH for any visible object and remove it if seen. NEVER perform a blind finger sweep — this can push the object deeper into the airway.
• For a conscious infant with mild obstruction: observe and monitor; allow continued coughing; do not perform blind interventions.

Definitions

Section Title

Choking Management (Foreign-Body Airway Obstruction — FBAO)

Common Mistakes

• Performing abdominal thrusts on an infant — NEVER. Infants require 5 back slaps + 5 chest thrusts.
• Performing abdominal thrusts on a pregnant or obese person — use CHEST THRUSTS instead.
• Intervening in a MILD obstruction — if the person can cough, speak, or breathe, encourage coughing and do not perform thrusts.
• Performing a blind finger sweep — only remove visible objects from the airway.
• Stopping CPR to check the airway after becoming unresponsive instead of starting compressions first — follow C-A-B: compressions first.

Exam Tips

• NLE may test communication techniques during a code — 'closed-loop communication' is the correct term and process.
• ETCO2 rising suddenly during CPR = likely ROSC. Stop compressions and check for a pulse.
• RA 9173 supports the nurse's accountability for both safe practice and professional development — debriefing aligns with this mandate.
• Documentation of each drug dose's exact time is essential — NLE scenarios may ask about correct sequence and timing of interventions.

Key Points

• The nurse's immediate priorities during cardiac arrest are: (1) Start compressions without delay, (2) Maintain compression quality throughout, (3) Coordinate AED/defibrillator arrival and use, (4) Minimize interruptions to maximize chest compression fraction.
• TEAM LEADER ROLE: A designated team leader directs the code, verbalizes the plan, names the current rhythm, announces the elapsed time and cycle count, and keeps all team members oriented.
• CLOSED-LOOP COMMUNICATION: The team leader gives a clear order → the receiver acknowledges by repeating the order back → the receiver confirms when the task is completed. This prevents missed doses, double doses, and errors in the noise of a resuscitation.
• ROLE ASSIGNMENT: Clear assignment of roles — compressor, ventilator, IV/IO access and drug administration, rhythm monitor, documentation, team leader — prevents chaos and duplication.
• SWITCH COMPRESSORS EVERY 2 MINUTES: Assign the next compressor before the 2-minute cycle ends, so the switch is seamless and compressions resume within seconds.
• DOCUMENTATION: Record the exact time and sequence of every intervention — compression start time, rhythm at each check, each drug given (drug, dose, route, time), each shock delivered (time, energy, result), and any procedures performed.
• SPEAK UP CULTURE: Any team member — regardless of seniority — should voice concern if they notice degraded compression quality, a prolonged pause, a drug about to be given in error, or any safety issue. This is supported by RA 9173's mandate for safe, competent nursing practice.
• FEEDBACK DEVICES: Cardiopulmonary feedback devices (accelerometers, visual/audio prompts on the defibrillator) provide objective real-time data on compression rate, depth, and recoil.
• END-TIDAL CO2 (ETCO2) MONITORING: A capnography probe measures CO2 exhaled with each ventilation. During CPR, ETCO2 reflects cardiac output. A sudden sustained rise in ETCO2 (above 40 mmHg) during CPR is a strong early indicator of ROSC.
• POST-EVENT DEBRIEFING: After every resuscitation event, the team should debrief — identify what went well, what needs improvement, and what can be done better in the next code. This is a quality improvement tool and a professional responsibility under RA 9173.

Definitions

Section Title

Nursing Management During a Code: Team Dynamics and Documentation

Common Mistakes

• No clear team leader designated — results in chaotic, disorganized resuscitation.
• No closed-loop communication — leads to missed drugs, double doses, or wrong route administration.
• Team members afraid to speak up about errors because of hierarchy — a culture of silence costs lives.
• Incomplete or delayed documentation — makes post-arrest analysis impossible.
• Neglecting debriefing — missed opportunity for team and individual improvement.

Exam Tips

• Hands-only CPR = for untrained bystanders. Healthcare providers always perform standard CPR with compressions AND ventilation.
• Rib fractures from CPR = expected, not negligent. Do not reduce compression force.
• DNR must be verified and documented before withholding resuscitation — always check the chart and ask the physician.
• In Philippine community nursing (NCM levels), CPR teaching is a core health promotion activity at the barangay level.

Key Points

• RIB FRACTURES and STERNAL FRACTURES are common consequences of even correctly performed CPR, especially in elderly patients. Do NOT reduce compression depth to avoid fractures — effective compressions save lives; fractures heal.
• GASTRIC INFLATION is common with bag-valve mask ventilation or mouth-to-mouth. Risk is reduced by giving only enough volume to see chest rise and not ventilating too rapidly.
• Nurses should reassure families that rib fractures do not mean CPR was done incorrectly — they are expected and acceptable side effects of life-saving compressions.
• HANDS-ONLY CPR (Compression-Only CPR): Recommended for untrained bystanders in the community. Provide continuous chest compressions at 100 to 120 per minute WITHOUT rescue breathing. This simplifies the intervention for lay bystanders and removes the barrier of performing mouth-to-mouth on a stranger.
• KEY TEACHING POINT: Imperfect CPR started early is always better than perfect CPR started late. The most common fatal error is delayed or absent bystander CPR.
• PATIENT/FAMILY EDUCATION in Philippine community health settings: Teach CPR during community health assemblies (barangay health stations), during prenatal classes, and as part of health education by community health nurses (NCM 103/104 context). Promote awareness of emergency contact numbers (911, local emergency services).
• ADVANCE DIRECTIVES (DNR/DNI): Respect valid Do Not Resuscitate (DNR) or Do Not Intubate (DNI) orders. Under RA 9173, the nurse must verify the existence and validity of advance directives before initiating or withholding resuscitation.
• Termination of resuscitation: Based on physician decision after considering duration of arrest, lack of ROSC, non-shockable rhythm, and no reversible causes. Exception: hypothermia — never terminate until the patient is rewarmed.

Definitions

Section Title

Complications, Patient/Family Education, and Hands-Only CPR

Common Mistakes

• Stopping or reducing compressions because of rib fracture sounds/feelings — continue high-quality compressions regardless.
• Teaching bystanders complex CPR when they are untrained — hands-only CPR is the recommended option for the general public.
• Failing to verify DNR/DNI orders before withholding or initiating CPR — creates legal and ethical liability.
• Terminating resuscitation in a hypothermic patient before rewarming — 'not dead until warm and dead.'