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🏥 MED-SURGICAL NURSING — NCLEX STUDY NOTES

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UNIT 1: FOUNDATIONS

The Nursing Process (ADPIE)

• Assessment → collect subjective (symptoms, history) & objective (vitals, labs, exam) data
• Diagnosis → identify nursing diagnoses (e.g., "Impaired Gas Exchange," "Decreased Cardiac Output")
• Planning → set SMART, measurable goals with the patient
• Implementation → carry out interventions (independent, collaborative, dependent)
• Evaluation → determine if goals were met; revise plan as needed

Priority-Setting Frameworks

• Maslow's Hierarchy: physiologic needs first (airway, breathing, circulation) → safety → love/belonging → esteem → self-actualization
• ABCs: Airway > Breathing > Circulation — always the first priority
• Acute vs. Chronic: acute/life-threatening conditions take priority over chronic stable ones
• SBAR: Situation, Background, Assessment, Recommendation — standard hand-off communication

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UNIT 2: FLUID, ELECTROLYTES & ACID-BASE BALANCE

Fluid Volume Deficit (Hypovolemia)

• Causes: hemorrhage, vomiting, diarrhea, burns, excessive sweating, diuretics
• S/S: ↑HR, ↓BP, orthostatic hypotension, dry mucous membranes, poor skin turgor, ↓urine output (<0.5 mL/kg/hr), flat neck veins, concentrated urine (SG >1.030)
• Labs: ↑BUN, ↑Hct, ↑serum sodium (if water loss > sodium loss)
• Nursing interventions: IV fluid replacement, monitor I&O, daily weights (1 kg = ~1 L fluid), fall precautions

Fluid Volume Excess (Hypervolemia)

• Causes: HF, renal failure, excessive IV fluids, cirrhosis
• S/S: ↑BP, bounding pulse, distended neck veins (JVD), S3 gallop, crackles, edema, weight gain
• Nursing interventions: restrict fluids/sodium, elevate HOB, daily weights, administer diuretics, monitor SpO₂

Key Electrolyte Imbalances

Acid-Base Balance

ROME mnemonic: Respiratory Opposite (pH↑ CO₂↓ or pH↓ CO₂↑); MEtabolic Equal (pH↑ HCO₃↑ or pH↓ HCO₃↓)

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UNIT 3: CARDIOVASCULAR DISORDERS

Hypertension

• Definition: BP ≥130/80 mmHg (AHA 2017); Stage 2 ≥140/90
• Risk factors: age, obesity, DM, smoking, family history, high sodium diet, sedentary lifestyle
• S/S: often asymptomatic ("silent killer"); may have headache (occipital), epistaxis, visual changes in hypertensive crisis
• Hypertensive crisis: BP >180/120 — can cause stroke, MI, AKI
• Medications:
  • ACE inhibitors / ARBs — first-line for DM; monitor for dry cough (ACEi), hyperkalemia, angioedema
  • Thiazide diuretics — first-line for uncomplicated HTN; monitor K⁺
  • Calcium channel blockers — amlodipine; watch for peripheral edema
  • Beta-blockers — metoprolol; do NOT abruptly discontinue (rebound HTN, MI)
• Patient teaching: DASH diet (↓ sodium <2 g/day), weight loss, exercise, no smoking/alcohol, medication adherence

Heart Failure (HF)

• Left-sided HF: backs up into lungs → pulmonary edema
  • S/S: dyspnea, orthopnea, PND (paroxysmal nocturnal dyspnea), crackles, frothy pink sputum, S3 gallop
• Right-sided HF: backs up into systemic circulation
  • S/S: JVD, peripheral pitting edema, hepatomegaly, ascites, weight gain
• HFrEF (EF <40%) vs HFpEF (EF ≥50%)
• NYHA Classification: I (no symptoms) → II (symptoms with moderate exertion) → III (symptoms with minimal exertion) → IV (symptoms at rest)
• Medications:
  • ACE inhibitors/ARBs + Beta-blockers + Aldosterone antagonists (spironolactone) = standard GDMT (guideline-directed medical therapy)
  • SGLT2 inhibitors (dapagliflozin, empagliflozin) — now recommended for HFrEF
  • Loop diuretics (furosemide) — for symptom relief; monitor K⁺, creatinine
  • Digoxin — reduces hospitalizations; narrow therapeutic range (0.5–2 ng/mL); toxicity signs: nausea, yellow-green halos, bradycardia
• Nursing interventions: daily weights (report >2 lb/day gain), strict I&O, HOB ≥30–45°, oxygen, restrict Na⁺/fluids, cardiac monitoring

Acute Coronary Syndrome (ACS)

• Spectrum: Unstable Angina → NSTEMI → STEMI
• Classic S/S: crushing substernal chest pain, radiation to left arm/jaw, diaphoresis, nausea, dyspnea
• WOMEN may present atypically: fatigue, nausea, back/jaw pain, no chest pain
• Diagnostics: 12-lead ECG (STEMI = ST elevation ≥1 mm in 2+ contiguous leads), Troponin (rises 3–4 hrs, peaks 12–24 hrs, stays elevated 7–10 days), CK-MB
• Immediate management (MONA):
  • Morphine (cautiously — may mask symptoms)
  • Oxygen (if SpO₂ <94%)
  • Nitrates (sublingual NTG; hold if BP <90 systolic, patient took PDE-5 inhibitor in last 24–48 hrs)
  • Aspirin 325 mg chewed immediately
• Reperfusion: PCI (percutaneous coronary intervention) preferred if available within 90 min; thrombolytics if PCI unavailable within 120 min
• Post-MI nursing care: monitor for dysrhythmias, reinfarction; early ambulation; cardiac rehab referral

Dysrhythmias

• Sinus Bradycardia (<60 bpm): treat if symptomatic — atropine, pacing
• Sinus Tachycardia (>100 bpm): treat underlying cause (pain, fever, anxiety, hypovolemia)
• Atrial Fibrillation (A-Fib):
  • Irregular irregularly irregular rhythm, no distinct P waves, variable ventricular rate
  • Risk: stroke (thrombus forms in LAA) — anticoagulate (warfarin INR 2–3, or NOACs)
  • Rate control: beta-blockers, diltiazem, digoxin
  • Rhythm control: cardioversion (ensure anticoagulated ≥3 weeks if AF >48 hours, or rule out LAA thrombus by TEE)
• Ventricular Tachycardia (V-Tach):
  • Pulseless V-Tach = CPR + defibrillation immediately
  • Stable V-Tach = amiodarone, lidocaine; synchronized cardioversion
• Ventricular Fibrillation: CPR + immediate defibrillation (unsynchronized)
• Asystole / PEA: CPR + epinephrine; find reversible causes (5 Hs & 5 Ts)

5 Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia 5 Ts: Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE), Thrombosis (MI)

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UNIT 4: RESPIRATORY DISORDERS

Pneumonia

• Types: Community-acquired (CAP), Hospital-acquired (HAP ≥48 hrs after admission), Ventilator-associated (VAP)
• S/S: fever/chills, productive cough, pleuritic chest pain, dyspnea, crackles/decreased breath sounds, SpO₂↓
• Diagnostics: CXR (lobar consolidation or infiltrates), sputum culture, CBC (↑WBC), blood cultures
• Pathogens: CAP → Streptococcus pneumoniae most common; atypical (Mycoplasma, Legionella, Chlamydia)
• Treatment: antibiotics (amoxicillin, azithromycin, fluoroquinolones), oxygen, fluids, antipyretics
• Nursing care: HOB ≥30°, encourage coughing/deep breathing, incentive spirometry, adequate hydration, oral care

COPD (Chronic Obstructive Pulmonary Disease)

• Two types: Chronic bronchitis ("blue bloater" — productive cough >3 months/year for 2+ years) and Emphysema ("pink puffer" — barrel chest, pursed-lip breathing)
• Mechanism: airflow obstruction → air trapping → ↑RV → barrel chest; triggered by smoking (90% of cases)
• S/S: chronic cough, dyspnea (particularly on exertion), wheezing, barrel chest
• ABG in COPD: chronic respiratory acidosis (↑CO₂, compensatory ↑HCO₃⁻)
• Oxygen caution: in COPD, drive to breathe is hypoxic (not hypercapnic) — keep SpO₂ 88–92% to avoid removing hypoxic drive; use low-flow O₂ (1–2 L/min)
• Medications: short-acting bronchodilators (SABAs like albuterol) for rescue; LABAs + LAMAs + inhaled corticosteroids for maintenance
• COPD Exacerbation treatment: SABAs + ipratropium, systemic steroids (prednisolone 5 days), antibiotics if purulent sputum, NIV (BiPAP) if hypercapnic
• Patient teaching: smoking cessation, flu/pneumococcal vaccines, pursed-lip breathing, energy conservation

Asthma

• Mechanism: reversible airway inflammation + bronchoconstriction triggered by allergens, exercise, cold air, infections
• S/S: wheezing, dyspnea, chest tightness, cough (especially at night/early morning)
• Peak expiratory flow (PEF): green (80–100% predicted) → yellow (50–79%) → red (<50%) → emergency
• Status asthmaticus: life-threatening asthma not responding to bronchodilators — silent chest = impending arrest
• Step therapy: SABA PRN → low-dose ICS → ICS + LABA → high-dose ICS + LABA → biologics (dupilumab, omalizumab for severe)
• Nursing: monitor for silent chest (very ominous), check inhaler technique, spacer use, avoid triggers

Pulmonary Embolism (PE)

• Virchow's Triad: Stasis + Endothelial injury + Hypercoagulability
• Risk factors: prolonged immobility, DVT, surgery, cancer, oral contraceptives, pregnancy, obesity
• S/S: sudden onset dyspnea, pleuritic chest pain, tachycardia, tachypnea, hemoptysis, hypoxia; massive PE → obstructive shock
• Classic presentation: dyspnea + tachycardia + risk factors = PE until proven otherwise
• Wells Score: used to estimate pre-test probability
• Diagnostics: CT pulmonary angiography (gold standard), V/Q scan if CIN risk, D-dimer (sensitive, not specific)
• Treatment: anticoagulation (UFH, LMWH, DOACs); systemic thrombolytics for massive PE with hemodynamic instability
• Nursing: O₂ supplementation, bed rest initially, analgesics, monitor anticoagulation, DVT prophylaxis

ARDS (Acute Respiratory Distress Syndrome)

• Definition: acute hypoxemic respiratory failure; PaO₂/FiO₂ ratio <300; bilateral infiltrates; not fully explained by cardiac failure
• Causes: sepsis (#1), aspiration, trauma, transfusion (TRALI), severe pneumonia
• Management: lung-protective ventilation (tidal volume 6 mL/kg ideal body weight, PEEP to maintain alveolar recruitment); conservative fluid management; prone positioning if PaO₂/FiO₂ <150
• Nursing: closely monitor ventilator settings, sedation, prevent VAP (bundle care), frequent repositioning

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UNIT 5: RENAL & GENITOURINARY DISORDERS

Acute Kidney Injury (AKI)

• Definition: sudden decline in kidney function; ↑creatinine ≥0.3 mg/dL within 48 hrs or ≥1.5× baseline within 7 days
• Three types:
  • Pre-renal (hypoperfusion): hypovolemia, HF, sepsis → concentrated urine (FeNa <1%), BUN:Cr ratio >20:1
  • Intrinsic/Intrarenal (parenchymal damage): ATN from ischemia or nephrotoxins (contrast, NSAIDs, aminoglycosides) → dilute urine (FeNa >2%)
  • Post-renal (obstruction): BPH, kidney stones, tumors → treated by relieving obstruction
• S/S: oliguria (<0.5 mL/kg/hr), ↑BUN/Creatinine, fluid overload, hyperkalemia, metabolic acidosis
• Nursing: strict I&O, daily weights, avoid nephrotoxins, renal diet (↓K⁺, ↓Na⁺, ↓phosphorus, ↑calories), monitor for dialysis indications

Chronic Kidney Disease (CKD)

• Stages: 1 (GFR ≥90) to 5 (GFR <15 = renal failure requiring replacement)
• Common causes: DM (most common in developed countries), HTN, glomerulonephritis
• Manifestations (uremic syndrome): fatigue, nausea, pruritus, metallic taste, uremic frost, peripheral neuropathy, pericarditis
• Complications: anemia (↓EPO → give darbepoetin/epoetin), hyperkalemia, metabolic acidosis, ↑phosphorus/↓calcium (secondary hyperparathyroidism → renal osteodystrophy)
• Hemodialysis (HD): 3× weekly, 3–4 hrs; monitor for hypotension, dialysis disequilibrium, vascular access (AV fistula — do not BP/IV in that arm)
• Peritoneal dialysis (PD): daily at home; monitor for peritonitis (cloudy effluent, pain, fever)

Urinary Tract Infection (UTI)

• Lower UTI (cystitis): dysuria, frequency, urgency, suprapubic pain, turbid/foul urine
• Upper UTI (pyelonephritis): above + flank pain (CVA tenderness), fever, chills, nausea/vomiting
• Diagnostics: UA (↑WBCs, nitrites, leukocyte esterase), urine culture (gold standard)
• Most common pathogen: E. coli (80%)
• Treatment: uncomplicated UTI → TMP-SMX or nitrofurantoin 3–7 days; pyelonephritis → fluoroquinolone 7–14 days
• Prevention: adequate fluids, wipe front-to-back, void after intercourse, avoid bubble baths, avoid holding urine

Benign Prostatic Hyperplasia (BPH)

• S/S: obstructive symptoms (hesitancy, weak stream, retention) + irritative symptoms (urgency, frequency, nocturia)
• Diagnostics: PSA (elevated), post-void residual >50 mL, transrectal ultrasound
• Treatment: alpha-blockers (tamsulosin — first-line; may cause orthostatic hypotension), 5-alpha reductase inhibitors (finasteride — reduces gland size, take 6–12 months for effect), TURP surgery
• Nursing post-TURP: monitor for hemorrhage, continuous bladder irrigation (CBI), expect pink/red urine initially, clot retention → irrigation; do NOT give enemas post-TURP

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UNIT 6: GASTROINTESTINAL DISORDERS

Peptic Ulcer Disease (PUD)

• Types: gastric ulcer (pain worse with eating) vs. duodenal ulcer (pain relieved with eating, worsens 2–3 hrs after)
• Causes: H. pylori (most common), NSAIDs, stress ulcers, Zollinger-Ellison syndrome
• Complications: hemorrhage (hematemesis, melena, ↓BP/↑HR), perforation (sudden severe pain → peritonitis → rigid board-like abdomen), gastric outlet obstruction
• Treatment: H. pylori → triple therapy (PPI + clarithromycin + amoxicillin × 14 days); NSAIDs → stop NSAID + PPI
• Nursing: monitor stool color (melena = upper GI bleed), vitals for hemorrhage, semi-Fowler's position, NG tube if needed

GI Bleeding

• Upper GI bleeding (above ligament of Treitz): hematemesis (vomiting blood), melena (black tarry stools); causes: ulcers, varices, Mallory-Weiss tear
• Lower GI bleeding: hematochezia (bright red blood per rectum); causes: diverticulosis (#1 cause of painless lower GI bleed), polyps, colorectal cancer, hemorrhoids, IBD
• Nursing priorities: two large-bore IV access, O₂, fluid resuscitation, blood transfusion prn, NPO, monitor vitals/Hgb, prepare for endoscopy

Inflammatory Bowel Disease (IBD)

• Treatment: aminosalicylates (mesalamine), corticosteroids (flares), azathioprine/6-MP, biologics (infliximab, adalimumab)
• Nursing: monitor for complications (fever, distension = toxic megacolon), nutrition (TPN if severe), skin care around stoma, medication adherence

Liver Cirrhosis

• Causes: alcoholic liver disease, hepatitis B/C, NAFLD
• Complications:
  • Portal hypertension → esophageal varices (risk of massive hemorrhage), ascites, splenomegaly
  • Ascites: manage with Na⁺ restriction, spironolactone ± furosemide, paracentesis
  • Hepatic encephalopathy: ↑NH₃ → confusion, asterixis (flapping tremor), coma
    • Treatment: lactulose (traps NH₃ in gut), rifaximin, low-protein diet (controversial)
  • Coagulopathy: ↓clotting factors → bleeding; give Vitamin K, FFP before procedures
  • Hepatorenal syndrome: functional renal failure in advanced cirrhosis
• Nursing: monitor mental status, abdominal girth (ascites), neurological checks, avoid hepatotoxic drugs (including acetaminophen >2 g/day), alcohol cessation

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UNIT 7: NEUROLOGICAL DISORDERS

Stroke (CVA — Cerebrovascular Accident)

• Ischemic stroke (87%): thrombotic or embolic occlusion of cerebral artery
• Hemorrhagic stroke (13%): rupture of blood vessel (HTN most common cause)
• S/S (FAST): Face drooping, Arm weakness, Speech difficulty, Time to call 911
• Other S/S: sudden severe headache "thunderclap" (SAH), vision loss, ataxia, vertigo
• Diagnostics: CT head (no contrast) FIRST → rules out hemorrhage before giving tPA; MRI more sensitive later
• Treatment:
  • Ischemic: IV tPA (alteplase) within 4.5 hours of symptom onset (contraindicated if hemorrhagic, recent surgery, bleeding disorder, BP >185/110)
  • Mechanical thrombectomy up to 24 hours for large vessel occlusion
  • Hemorrhagic: control BP (labetalol, nicardipine), reverse anticoagulation, neurosurgical consult
• Nursing: ABC priority, NPO until swallowing assessment, aspiration precautions, HOB 30° (ischemic) or flat (controversial per facility), BP management, neuro checks q1hr initially, fall precautions

Increased Intracranial Pressure (IICP)

• Cushing's Triad (late sign of brain herniation): ↑BP (widened pulse pressure) + Bradycardia + Irregular respirations — MEDICAL EMERGENCY
• S/S: early: headache, vomiting (projectile), restlessness, ↓LOC; late: Cushing's triad, pupil changes (blown pupil = herniation)
• Nursing interventions: HOB 30° (neutral position, no neck flexion), avoid clustering activities, maintain normothermia, avoid Valsalva maneuver (no straining, constipation), dim/quiet environment, O₂ (keep PaCO₂ 35–45, hyperventilate temporarily for acute herniation to vasoconstrict)
• Medications: Mannitol (osmotic diuretic — monitor serum osmolality, hold if >320 mOsm/L), hypertonic saline, dexamethasone (for tumor-related edema), elevate HOB

Seizures

• Types: focal (partial) vs. generalized (absence, tonic-clonic, atonic, myoclonic)
• Status epilepticus: seizure >5 min OR recurrent seizures without regaining consciousness — medical emergency
• Nursing during a seizure:
  • Stay with the patient, call for help
  • Time the seizure
  • Protect from injury (padded side rails, move sharp objects)
  • Turn to lateral position (prevent aspiration)
  • NEVER force anything into the mouth
  • Loosen clothing
  • Post-ictal: place in recovery position, reorient, document
• Medications: benzodiazepines (first-line for acute: lorazepam, diazepam), phenytoin/fosphenytoin, valproate, levetiracetam

Meningitis

• Bacterial (most severe): Neisseria meningitidis, Streptococcus pneumoniae
• Classic triad: fever + nuchal rigidity (stiff neck) + photophobia/headache; + altered mental status
• Signs: Kernig's sign (unable to extend knee when hip flexed 90°) and Brudzinski's sign (neck flexion → involuntary knee flexion)
• Diagnosis: lumbar puncture (LP) — cloudy CSF, ↑WBC, ↑protein, ↓glucose; blood cultures before LP if possible
• Treatment: IV antibiotics immediately (do not delay for LP); ceftriaxone + dexamethasone; droplet precautions × 24 hrs for bacterial meningitis (then discontinue after 24 hrs antibiotic therapy)
• Nursing: seizure precautions, dim lighting, quiet room, monitor vitals/neuro status, antipyretics

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UNIT 8: ENDOCRINE DISORDERS

Diabetes Mellitus

• S/S: shakiness, diaphoresis, tachycardia, pallor, anxiety, headache, confusion; severe: seizures, coma
• Rule of 15: 15 g fast-acting carbs → recheck in 15 min → repeat if still <70 mg/dL
• Unconscious patient: IV dextrose (D50W) or IM glucagon; never give oral glucose to unconscious patient

• Occurs in T1DM (rarely T2DM)
• Triggers: missed insulin, infection, illness, new onset DM
• S/S: polyuria, polydipsia, Kussmaul respirations (deep/rapid to blow off CO₂), fruity breath, nausea, vomiting, abdominal pain
• Labs: blood glucose >250, anion gap metabolic acidosis (pH <7.3), ketones in urine/blood, ↓K⁺ (initially may be normal/high, but total body K⁺ depleted)
• Treatment: IV fluids (0.9% NaCl → 0.45% NaCl), regular insulin drip, potassium replacement (BEFORE insulin if K⁺ <3.5 mEq/L — never give insulin when K⁺ <3.3), monitor glucose/K⁺/pH hourly

• Occurs in T2DM, elderly; triggered by illness, infection
• S/S: severe hyperglycemia (>600 mg/dL), profound dehydration, altered mental status; NO ketosis or acidosis
• Treatment: aggressive IV fluid replacement, insulin, electrolyte monitoring
• High mortality — can cause cerebral edema if corrected too rapidly

Thyroid Disorders

• S/S: fatigue, cold intolerance, constipation, weight gain, bradycardia, myxedema (non-pitting edema), depression, dry skin/coarse hair, slowed DTR
• Labs: ↑TSH, ↓T3/T4
• Myxedema coma: hypothyroid crisis — hypothermia, bradycardia, hypotension, coma — medical emergency; IV levothyroxine
• Treatment: levothyroxine (T4 — take in morning on empty stomach, separate from calcium, iron, antacids)

• S/S: heat intolerance, weight loss, diarrhea, tachycardia, exophthalmos (Graves' only), anxiety, tremor, atrial fibrillation, pretibial myxedema
• Labs: ↓TSH, ↑T3/T4
• Thyroid storm: life-threatening hyperthyroid crisis — hyperthermia >103°F, extreme tachycardia, HF, altered mental status; triggered by infection, surgery, trauma
  • Treatment: PTU (blocks synthesis + conversion) → Lugol's iodine (1 hr after PTU) → beta-blockers (propranolol) → steroids → cooling blankets
• Treatment options: antithyroid drugs (PTU, methimazole), radioactive iodine (RAI — contraindicated in pregnancy), thyroidectomy

Adrenal Disorders

• Cause: autoimmune destruction of adrenal cortex (most common); ↓cortisol + ↓aldosterone
• S/S: fatigue, hypotension, hyperpigmentation (bronze skin — classic), weight loss, hyponatremia, hyperkalemia, hypoglycemia
• Addisonian crisis: triggered by stress (illness, surgery, trauma); severe hypotension → shock, severe weakness, fever; MEDICAL EMERGENCY
• Treatment: IV hydrocortisone + fluid/Na⁺ replacement; long-term oral corticosteroids; stress dosing when sick

• Causes: exogenous steroids (most common), pituitary adenoma (Cushing's disease), adrenal or ectopic tumor
• S/S (CUSHINGS mnemonic): Central obesity, Unusual bruising, Striae (purple), Hirsutism, Infections ↑, No energy (fatigue), Glucose ↑, Skin thinning/Moon face/Buffalo hump
• Labs: ↑cortisol, ↑glucose, ↓K⁺, ↑Na⁺, ↓ACTH (if adrenal) or ↑ACTH (if pituitary/ectopic)
• Treatment: taper exogenous steroids gradually; surgery for tumors; adrenal enzyme inhibitors

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UNIT 9: MUSCULOSKELETAL DISORDERS

Fractures

• S/S (6 Ps): Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (coolness)
• Fat embolism syndrome: hours to days after long bone/pelvic fractures — petechiae (chest, axilla), confusion, hypoxia
• Compartment syndrome: pressure in muscle compartment → ischemia; S/S: severe pain (especially with passive stretch), paresthesia, pallor, pulselessness; treatment = emergency fasciotomy
• Nursing priorities: neurovascular checks q1–2 hrs, elevate limb (not above heart if perfusion compromised), ice, immobilize
• Hip fracture (common in elderly): post-op nursing — maintain hip abduction pillow, avoid hip flexion >90°, adduction, internal rotation (depends on approach — posterior = most common, requires hip precautions)

Osteoporosis

• Risk factors: female, post-menopausal, low BMI, smoking, steroids, family history, low calcium/Vitamin D intake
• Diagnosis: DEXA scan — T-score ≤–2.5 (osteoporosis); –1.0 to –2.5 (osteopenia)
• Treatment: calcium (1200 mg/day), Vitamin D (800–1000 IU/day), weight-bearing exercise, bisphosphonates (alendronate — take on empty stomach with 8 oz water, sit upright 30 min to prevent esophageal irritation), denosumab, teriparatide
• Nursing: fall prevention, home safety assessment, correct technique for bisphosphonates

Rheumatoid Arthritis (RA) vs. Osteoarthritis (OA)

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UNIT 10: PERIOPERATIVE NURSING

Preoperative Phase

• Informed consent: surgeon's responsibility to obtain; nurse's role = witness, ensure patient understanding
• Pre-op teaching: deep breathing exercises, incentive spirometry, leg exercises (prevent DVT), early ambulation expectations, pain management options
• Pre-op assessments: allergies (especially latex, iodine, shellfish), medications (hold anticoagulants, aspirin, metformin), NPO status (solids 8 hrs, clear liquids 2 hrs before surgery), baseline vitals/labs
• Surgical checklist: correct patient (2 identifiers), correct site, correct procedure; site marking by surgeon; time-out before incision

Intraoperative Phase

• Roles: circulating nurse (outside sterile field, documents, coordinates), scrub nurse/tech (inside sterile field, passes instruments)
• Anesthesia types: general, regional (spinal, epidural), local, MAC (monitored anesthesia care)
• Positioning risks: pressure injuries, nerve damage (brachial plexus, ulnar nerve), compartment syndrome; reposition q2hrs post-op

Postoperative Phase (PACU and Floor)

1. Airway & breathing (most critical — laryngospasm, aspiration, respiratory depression from anesthesia/opioids)
2. Circulation (vitals q15 min → q30 min → q1hr)
3. Level of consciousness / Aldrete Score (before transfer from PACU)
4. Pain assessment
5. Wound/dressing inspection
6. IV lines, catheters, drains

• Multimodal analgesia: scheduled acetaminophen + NSAIDs + opioids PRN
• PCA (Patient-Controlled Analgesia): only the patient presses the button; monitor for respiratory depression, nausea
• Epidural analgesia: monitor motor/sensory return, urinary retention, hypotension, respiratory depression

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UNIT 11: ONCOLOGY NURSING

Cancer Basics

• Warning signs (CAUTION mnemonic): Change in bowel/bladder habits, A sore that doesn't heal, Unusual bleeding/discharge, Thickening/lump, Indigestion/dysphagia, Obvious changes in warts/moles, Nagging cough/hoarseness
• Tumor staging (TNM): T = tumor size, N = node involvement, M = metastasis; Stage I (local) → Stage IV (distant metastasis)

Chemotherapy

• Cell-cycle specific drugs: kill actively dividing cells (e.g., antimetabolites, plant alkaloids)
• Common side effects: myelosuppression (↓WBC, ↓RBC, ↓platelets), nausea/vomiting, alopecia, mucositis, peripheral neuropathy, cardiotoxicity (anthracyclines)
• Nadir: lowest point of blood counts (typically 7–14 days after chemo)
• Neutropenic precautions (ANC <500): private room, no fresh flowers/plants, no raw fruits/vegetables, hand hygiene, avoid sick contacts, monitor for fever (>38.3°C = oncological emergency → cultures + broad-spectrum antibiotics immediately)
• Thrombocytopenic precautions (platelets <50,000): electric razor, soft toothbrush, avoid IM injections/rectal temps, fall precautions; <20,000 → spontaneous hemorrhage risk

Oncologic Emergencies

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UNIT 12: INFECTION CONTROL & ISOLATION PRECAUTIONS

Transmission-Based Precautions

C. difficile: use soap and water (not hand sanitizer — alcohol does NOT kill spores); contact precautions

Key Isolation Mnemonics

• "SMASHED" for Airborne diseases: Smallpox, Measles, Aspergillosis (immunocompromised), SARS, HIV (primary infection with PCP), Ebola? (Airborne + Contact), Disseminated TB/Chickenpox
• My Patients Don't Fly for Droplet: Mumps, Pertussis, Diphtheria, Flu

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UNIT 13: CRITICAL CARE CONCEPTS

Shock

• Definition: inadequate tissue perfusion → cellular hypoxia
• Types:

  Type	Mechanism	Example	Hemodynamics
  Hypovolemic	↓preload (fluid/blood loss)	Hemorrhage, burns	↑HR, ↓BP, ↓CO, ↑SVR
  Cardiogenic	↓contractility	MI, HF	↑HR, ↓BP, ↓CO, ↑SVR, ↑PCWP
  Distributive/Septic	↓SVR (vasodilation)	Sepsis	↑HR, ↓BP, ↑CO (early), ↓SVR
  Obstructive	Physical obstruction	PE, tension pneumothorax, tamponade	↑HR, ↓BP, ↓CO
  Neurogenic	Loss of sympathetic tone	SCI	↓HR, ↓BP, ↓SVR
  Anaphylactic	Massive histamine release	Allergy, bee sting	↑HR, ↓BP, ↓SVR

• Nursing: two large-bore IVs, O₂, fluid challenge (except cardiogenic), vasopressors (norepinephrine first-line for septic shock), monitor urine output, trending MAP ≥65 mmHg

Sepsis (Surviving Sepsis Campaign — Hour-1 Bundle)

1. Measure lactate (if >2 mmol/L = sepsis with hypoperfusion; >4 = septic shock)
2. Blood cultures × 2 sets before antibiotics
3. Administer broad-spectrum antibiotics within 1 hour
4. IV crystalloids 30 mL/kg for hypotension/lactate ≥4
5. Vasopressors for MAP <65 despite fluids → norepinephrine

Pain, Agitation, and Delirium (ICU)

• CAM-ICU tool for delirium assessment in mechanically ventilated patients
• ABCDEF bundle: Assess/treat pain; Both SAT + SBT (spontaneous awaking and breathing trials); Choice of sedation (minimize benzodiazepines); Delirium assessment/management; Early mobility; Family engagement
• CIWA protocol: for alcohol withdrawal monitoring and treatment (benzodiazepines — diazepam, lorazepam)

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QUICK NCLEX PHARMACOLOGY REFERENCE

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QUICK REFERENCE: NORMAL LAB VALUES

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TOP NCLEX TEST-TAKING TIPS FOR MED-SURG

1. Always assess first (unless the situation is life-threatening — then act immediately)
2. ABCs — if a patient is not breathing/has no pulse, CPR starts before anything else
3. Maslow — physiologic needs before psychosocial
4. Unstable patients come first — prioritize based on acuity, not time of last assessment
5. Delegate carefully: RN cannot delegate assessment, teaching, evaluation, or care for unstable patients to LPN/UAP
6. When in doubt — check the patient (not the monitor, not the chart)
7. Comfort vs. cure: in end-of-life care, comfort is the priority; avoid interventions that do not align with patient wishes
8. Safe medication practice: "Rights" — Right patient, drug, dose, route, time, documentation, reason, response
9. Therapeutic communication: acknowledge feelings first; avoid why questions, false reassurance, clichés
10. Priority with multiple patients: go to the patient with the most life-threatening, acute, unexpected change first

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