Medical-Surgical Nursing

Medical-surgical nursing is the care of adult patients with acute and chronic medical conditions and of patients before, during, and after surgery. This article organizes the core content by body system and pairs each disorder with the assessment findings it produces and the nursing actions those findings demand. Throughout, the goal is to think like a nurse: what does this disease do to the body, what will I see, what do I do first, and what must I report.

How to Use This Article

Three habits make med-surg content usable on the licensure exam and at the bedside.

First, work from pathophysiology to findings rather than memorizing lists. If a disease reduces forward cardiac output, expect fatigue, hypotension, cool extremities, and reduced urine output. If it backs blood up behind a failing chamber, expect congestion in whatever vascular bed drains into that chamber.

Second, prioritize with a stable framework. Airway, breathing, circulation comes first, then acute changes in level of consciousness, then safety, then comfort and teaching. Among stable findings, the abnormal one that is new, sudden, or unexpected outranks the abnormal one that is chronic and expected.

Third, know the difference between an assessment and an intervention. Many exam questions are answered correctly by choosing to look, listen, or measure before acting, unless the patient is in immediate danger, in which case acting comes first.

Fluid, Electrolyte, and Acid-Base Balance

Fluid Volume

Fluid volume deficit presents with thirst, dry mucous membranes, poor skin turgor over the sternum or forehead, flat neck veins, tachycardia, orthostatic hypotension, decreased urine output with concentrated dark urine, elevated urine specific gravity, elevated hematocrit and blood urea nitrogen, and acute weight loss. Fluid volume excess presents with bounding pulse, distended neck veins, crackles, dyspnea, peripheral or sacral edema, and acute weight gain.

Nursing application: daily weight taken at the same time, on the same scale, in similar clothing is the single most reliable indicator of fluid status. A gain of one kilogram equals roughly one liter of retained fluid. Intake and output records support the weight but do not replace it.

Key Electrolytes

Approximate adult reference ranges are sodium 135 to 145 mEq/L, potassium 3.5 to 5.0 mEq/L, total calcium 8.5 to 10.5 mg/dL, magnesium 1.5 to 2.5 mEq/L, and phosphorus 2.5 to 4.5 mg/dL. Values vary slightly by laboratory.

Hyponatremia produces neurologic findings because water shifts into brain cells: headache, confusion, lethargy, muscle cramps, and with severe or rapid drops, seizures. Hypernatremia produces thirst, dry sticky mucous membranes, restlessness, and agitation. Correct either one slowly; rapid correction of sodium in either direction causes serious neurologic injury.

Hypokalemia produces muscle weakness, leg cramps, decreased bowel sounds and ileus, shallow respirations from weak respiratory muscles, and electrocardiogram changes including flattened T waves, ST depression, and the appearance of U waves. It also markedly increases digoxin toxicity risk. Hyperkalemia produces muscle weakness, paresthesia, and peaked T waves progressing to a widened QRS and cardiac arrest.

Nursing application: potassium is never given by intravenous push and is never given undiluted. It is always diluted and infused on a pump, with the rate limited per facility policy, and the site is checked frequently because potassium is irritating to veins. Adequate urine output should be confirmed before giving potassium.

Hypocalcemia produces tetany, tingling around the mouth and in the fingers, hyperactive reflexes, a positive Chvostek sign (facial twitching when the facial nerve is tapped), a positive Trousseau sign (carpal spasm when a blood pressure cuff is inflated above systolic pressure), laryngospasm, and seizures. Hypercalcemia produces the opposite: lethargy, muscle weakness, decreased reflexes, constipation, and kidney stones.

Hypomagnesemia mimics hypocalcemia with tremors, hyperactive reflexes, and increased risk of torsades de pointes. Hypermagnesemia causes depressed reflexes, respiratory depression, and hypotension; the antidote is intravenous calcium gluconate.

Acid-Base Interpretation

Normal arterial values are pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and bicarbonate 22 to 26 mEq/L.

Use the memory aid ROME: Respiratory Opposite, Metabolic Equal. In respiratory disorders the pH and the PaCO2 move in opposite directions; in metabolic disorders the pH and the bicarbonate move in the same direction.

Respiratory acidosis (low pH, high PaCO2) results from hypoventilation: chronic obstructive pulmonary disease exacerbation, oversedation, opioid overdose, neuromuscular weakness, or atelectasis. Respiratory alkalosis (high pH, low PaCO2) results from hyperventilation: anxiety, pain, fever, early sepsis, or pulmonary embolism. Metabolic acidosis (low pH, low bicarbonate) results from diabetic ketoacidosis, kidney failure, lactic acidosis from shock, or prolonged diarrhea. Metabolic alkalosis (high pH, high bicarbonate) results from prolonged vomiting, nasogastric suction, or excessive antacid use.

Cardiovascular Disorders

Coronary Artery Disease and Acute Coronary Syndrome

Atherosclerotic plaque narrows the coronary arteries. Stable angina occurs with predictable exertion and is relieved by rest and nitroglycerin. Unstable angina occurs at rest, is new, or is worsening in frequency and severity, and it signals impending infarction. Myocardial infarction occurs when a plaque ruptures and a thrombus occludes the vessel, causing myocardial necrosis.

Classic findings include crushing substernal chest pain that may radiate to the jaw, neck, left arm, or back, along with diaphoresis, nausea, dyspnea, and a sense of impending doom. Women, older adults, and people with diabetes often present atypically with fatigue, epigastric discomfort, shortness of breath alone, or new confusion. Silent infarction is common in diabetes because of autonomic neuropathy.

Diagnostics: a twelve-lead electrocardiogram should be obtained within ten minutes of presentation. ST elevation indicates an ST elevation myocardial infarction requiring emergent reperfusion. Troponin I and T are the most specific cardiac markers; they begin to rise about three to four hours after injury, peak within about twelve to twenty-four hours, and remain elevated for up to ten to fourteen days.

Nursing interventions: keep the patient on bed rest with the head of the bed elevated, apply oxygen if the oxygen saturation is below ninety percent or the patient is dyspneic, obtain intravenous access, and give aspirin to chew, nitroglycerin, and analgesia as ordered while monitoring the cardiac rhythm continuously. Nitroglycerin is withheld if the systolic blood pressure is below ninety mm Hg or has fallen substantially from baseline, and it is absolutely contraindicated within twenty-four to forty-eight hours of a phosphodiesterase type 5 inhibitor such as sildenafil or tadalafil because of the risk of profound hypotension.

Nursing application: the most common cause of death in the first hours after infarction is a lethal dysrhythmia, most often ventricular fibrillation. Continuous rhythm monitoring and immediate availability of a defibrillator are not optional. New premature ventricular contractions, ventricular tachycardia, or a new bundle branch block are reported at once.

Heart Failure

Left-sided failure backs blood into the lungs and produces dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles, a persistent dry or frothy pink-tinged cough, an S3 gallop, and fatigue. Right-sided failure backs blood into the systemic venous system and produces jugular venous distention, dependent and sacral edema, hepatomegaly, ascites, and weight gain. Left-sided failure is the most common cause of right-sided failure.

B-type natriuretic peptide rises with ventricular stretch and helps distinguish cardiac dyspnea from pulmonary causes; a level above about one hundred pg/mL supports heart failure, and higher levels correlate with greater severity.

Nursing interventions: elevate the head of the bed to high Fowler position, give oxygen, administer diuretics and monitor the potassium level, restrict sodium and often fluid, weigh daily, and balance activity with rest. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, and aldosterone antagonists improve survival and are continued even when the patient feels well.

Nursing application: teach the patient to weigh every morning after voiding and before breakfast, and to call the provider for a gain of two to three pounds in one day or five pounds in one week. That single instruction prevents more readmissions than almost any other teaching point.

Acute pulmonary edema is a medical emergency: severe dyspnea, anxiety, frothy pink sputum, crackles throughout the lung fields, and hypoxemia. Sit the patient upright with legs dependent, give high-flow oxygen, and prepare for intravenous furosemide, nitrates, and possible noninvasive positive pressure ventilation.

Hypertension

Hypertension is usually asymptomatic until organ damage occurs, which is why it is called the silent killer. Complications include stroke, myocardial infarction, heart failure, kidney failure, and retinopathy.

Nursing application: teach the DASH eating pattern, sodium restriction, weight loss, aerobic activity, limited alcohol, and smoking cessation. Warn about orthostatic hypotension with antihypertensives, especially alpha blockers and vasodilators, and teach the patient to change positions slowly. Emphasize that feeling fine is not a reason to stop the medication; nonadherence is the leading cause of treatment failure.

Hypertensive crisis with a systolic pressure above about one hundred eighty mm Hg accompanied by headache, blurred vision, chest pain, or neurologic change requires emergent evaluation and controlled, gradual lowering of pressure.

Dysrhythmias

Atrial fibrillation produces an irregularly irregular rhythm with no discernible P waves and a pulse deficit between apical and radial rates. Blood pools in the fibrillating atria, so the major risk is thromboembolic stroke; anticoagulation is central to management. Rate control and, in selected patients, rhythm control or ablation follow.

Ventricular tachycardia with a pulse in an unstable patient calls for synchronized cardioversion; without a pulse it is treated as cardiac arrest with defibrillation and cardiopulmonary resuscitation. Ventricular fibrillation is always pulseless and requires immediate defibrillation. Asystole and pulseless electrical activity are not shockable; they are treated with compressions, epinephrine, and correction of reversible causes.

Symptomatic bradycardia is treated with atropine, and if that fails, with transcutaneous pacing.

Peripheral Vascular Disease

Peripheral arterial disease produces intermittent claudication, pain relieved by dangling the legs, diminished or absent pulses, cool and shiny hairless skin, thick nails, pallor on elevation, dependent rubor, and painful ulcers on the toes or lateral malleolus. Venous insufficiency produces aching heaviness relieved by elevation, warm skin, brown hemosiderin staining, edema, and shallow weeping ulcers near the medial malleolus.

Nursing application: elevate legs for venous disease and avoid elevation for arterial disease. Compression stockings help venous disease and are dangerous in significant arterial disease. Never apply heat directly to an ischemic or neuropathic extremity.

Deep vein thrombosis presents with unilateral calf or thigh swelling, warmth, redness, and tenderness. Do not massage the extremity. Anticoagulation is the treatment; the feared complication is pulmonary embolism.

Selected Cardiac Medications

Digoxin increases contractility and slows conduction. The therapeutic serum level is roughly 0.5 to 2.0 ng/mL, with lower targets used in heart failure. Toxicity presents with anorexia, nausea, vomiting, visual disturbances such as halos or yellow-green vision, confusion, and bradycardia or new dysrhythmias. Hold the dose and notify the provider if the apical pulse is below sixty beats per minute in an adult, counted for a full minute. Hypokalemia potentiates toxicity.

Beta blockers reduce heart rate, contractility, and blood pressure. Hold and reassess for bradycardia or hypotension per parameters, do not stop abruptly because of rebound ischemia and hypertension, and be aware they can mask the tachycardia and tremor of hypoglycemia.

Angiotensin converting enzyme inhibitors cause a dry persistent cough, hyperkalemia, and rarely angioedema, which is an airway emergency. Monitor potassium and kidney function.

Warfarin is monitored by the international normalized ratio, with a usual therapeutic range of 2.0 to 3.0 for most indications; the antidote is vitamin K. Heparin is monitored by activated partial thromboplastin time at about 1.5 to 2.5 times control; the antidote is protamine sulfate. A platelet count that falls sharply after several days of heparin suggests heparin-induced thrombocytopenia, and all heparin must be stopped.

Respiratory Disorders

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease encompasses emphysema, in which alveolar walls are destroyed and air trapping occurs, and chronic bronchitis, in which airway inflammation and mucus production dominate. Findings include a prolonged expiratory phase, barrel chest, use of accessory muscles, wheezes and diminished breath sounds, chronic productive cough, clubbing, and weight loss.

Nursing interventions: teach pursed-lip breathing to prevent airway collapse on exhalation, diaphragmatic breathing, tripod positioning, energy conservation, adequate hydration to thin secretions, small frequent high-calorie meals because eating is tiring and a full stomach worsens dyspnea, and smoking cessation, which is the only intervention that slows disease progression.

Nursing application: many patients with advanced disease are chronic carbon dioxide retainers. Oxygen is titrated to the lowest effective flow, commonly targeting an oxygen saturation of about eighty-eight to ninety-two percent, because excessive oxygen can worsen ventilation-perfusion mismatch and blunt respiratory drive. Oxygen is never withheld from a hypoxemic patient, but it is given deliberately and monitored.

Asthma

Asthma is reversible airway inflammation, bronchospasm, and mucus plugging. Findings include wheezing, chest tightness, cough that is often worse at night, prolonged expiration, and decreased peak expiratory flow.

Nursing application: a sudden absence of wheezing in a patient who is still in distress is ominous, not reassuring. It means airflow has become too limited to generate sound and signals impending respiratory failure. Escalate immediately.

Medication teaching: use the short-acting beta agonist rescue inhaler first, wait the recommended interval, then use the inhaled corticosteroid, and rinse the mouth after the corticosteroid to prevent oral candidiasis. A spacer improves delivery. Peak flow in the green zone is eighty to one hundred percent of personal best, yellow is fifty to seventy-nine percent and signals caution, and red is below fifty percent and requires rescue medication and prompt help.

Pneumonia

Pneumonia is infection and inflammation of lung parenchyma with consolidation. Findings include fever, chills, productive cough, pleuritic chest pain, tachypnea, crackles, bronchial breath sounds over consolidated areas, dullness to percussion, increased tactile fremitus, and hypoxemia.

Nursing interventions: obtain sputum cultures before starting antibiotics when possible, give antibiotics promptly, encourage fluids, provide incentive spirometry and coughing and deep breathing, position with the good lung down when one lung is affected to optimize perfusion to the better lung, and mobilize the patient early.

Nursing application: in older adults the presenting sign of pneumonia is frequently new confusion, a fall, or decreased appetite rather than fever and cough. Treat new confusion in an older adult as a red flag requiring investigation.

Tuberculosis

Tuberculosis is caused by Mycobacterium tuberculosis and spreads by the airborne route. Findings include a cough lasting more than three weeks, hemoptysis, night sweats, low-grade afternoon fever, fatigue, and unintentional weight loss.

Infection control: place the patient in an airborne infection isolation room with negative pressure, wear a fitted N95 respirator or higher, keep the door closed, and place a surgical mask on the patient during transport outside the room. Diagnosis is confirmed by sputum acid-fast bacillus smears and culture; a positive skin test indicates exposure, not active disease.

Medications: rifampin turns urine, sweat, and tears orange and reduces the effectiveness of oral contraceptives. Isoniazid is hepatotoxic and causes peripheral neuropathy, which is why pyridoxine (vitamin B6) is given with it. Pyrazinamide is hepatotoxic and raises uric acid. Ethambutol can cause optic neuritis, so the patient reports any change in vision or color discrimination. Therapy lasts many months, and adherence, often by directly observed therapy, is the central nursing concern.

Pulmonary Embolism

A thrombus, usually from a deep vein thrombosis, occludes pulmonary arterial flow. Onset is sudden: dyspnea, pleuritic chest pain, tachypnea, tachycardia, anxiety, and sometimes hemoptysis or syncope. Massive embolism causes hypotension and cardiac arrest.

Nursing interventions: raise the head of the bed, give oxygen, notify the rapid response team or provider immediately, obtain intravenous access, and anticipate computed tomography pulmonary angiography, anticoagulation, and in severe cases thrombolysis or embolectomy. Prevention through early ambulation, sequential compression devices, and prophylactic anticoagulation is the highest-value nursing action.

Acute Respiratory Distress Syndrome

Diffuse alveolar-capillary membrane injury causes noncardiogenic pulmonary edema. The hallmark is refractory hypoxemia, meaning the oxygen saturation does not improve despite increasing supplemental oxygen, with bilateral infiltrates on chest imaging and no evidence of cardiogenic cause. Management is mechanical ventilation with low tidal volume lung-protective settings, positive end-expiratory pressure, prone positioning in selected patients, and treatment of the underlying cause, commonly sepsis, aspiration, trauma, or pancreatitis.

Chest Tubes

A chest tube drains air, blood, or fluid from the pleural space and restores negative pressure so the lung can reexpand.

Expected findings include gentle tidaling, which is fluctuation of the fluid level in the water seal chamber with respiration, and intermittent bubbling in the water seal only when the patient coughs or exhales in the case of a pneumothorax. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires assessment of connections and the insertion site. Cessation of tidaling can mean the lung has reexpanded or that the tubing is obstructed or kinked.

Nursing application: keep the drainage system upright and below chest level, do not routinely clamp the tube because clamping can create a tension pneumothorax, do not strip or milk the tubing, and keep sterile occlusive dressing supplies at the bedside. If the tube becomes disconnected from the drainage system, place the end in sterile water. If the tube is pulled out of the chest, cover the site with a dressing taped on three sides and notify the provider immediately.

Renal and Genitourinary Disorders

Acute Kidney Injury

Acute kidney injury is a sudden decline in kidney function classified as prerenal (hypoperfusion from hypovolemia, heart failure, or shock), intrarenal (direct damage from nephrotoxins, contrast media, aminoglycosides, or acute tubular necrosis), or postrenal (obstruction from stones, tumors, or prostatic enlargement).

The classic course has an oliguric phase with rising blood urea nitrogen and creatinine, hyperkalemia, metabolic acidosis, and fluid overload, followed by a diuretic phase in which large volumes of dilute urine are produced and the risks shift to hypovolemia and hypokalemia, and finally a recovery phase.

Nursing application: hyperkalemia is the most immediately lethal complication. Monitor the electrocardiogram, restrict potassium, and anticipate calcium gluconate to stabilize the myocardium, insulin with dextrose or a beta agonist to shift potassium into cells, and a potassium binder or dialysis to remove it. Calcium gluconate protects the heart but does not lower the serum potassium level.

Chronic Kidney Disease

Progressive irreversible nephron loss produces uremia, fluid overload, hypertension, hyperkalemia, hyperphosphatemia with resulting hypocalcemia and bone disease, metabolic acidosis, and anemia from reduced erythropoietin production.

Nursing interventions: restrict sodium, potassium, phosphorus, and usually fluid; provide adequate calories with controlled high-quality protein as prescribed; give phosphate binders with meals so they bind dietary phosphorus; administer erythropoiesis-stimulating agents and iron for anemia; and avoid nephrotoxic drugs including nonsteroidal anti-inflammatory drugs and contrast media where possible.

Dialysis Access and Care

For an arteriovenous fistula or graft, palpate for a thrill and auscultate for a bruit every shift. Never take blood pressure, draw blood, or start an intravenous line in the access extremity, and avoid constrictive clothing or sleeping on that arm.

Hold dialyzable medications, including many antihypertensives, until after treatment unless otherwise ordered, and weigh the patient before and after dialysis. Disequilibrium syndrome, caused by rapid solute shifts, presents with headache, nausea, restlessness, and confusion and requires slowing or stopping the treatment.

In peritoneal dialysis, cloudy effluent with abdominal pain and fever indicates peritonitis and must be reported and cultured. Outflow that is less than inflow suggests catheter obstruction or constipation; reposition the patient and check for kinks.

Urinary Tract Infection and Pyelonephritis

Lower tract infection causes dysuria, frequency, urgency, and suprapubic discomfort. Upper tract infection adds flank pain, costovertebral angle tenderness, fever, and chills. In older adults, new confusion, incontinence, or falls may be the only presentation.

Nursing application: prevention centers on hydration, complete bladder emptying, front-to-back perineal hygiene, and avoiding unnecessary indwelling catheters. When a catheter is required, maintain a closed system, keep the bag below bladder level and off the floor, and remove it at the earliest opportunity.

Urolithiasis

Renal calculi cause severe colicky flank pain radiating to the groin, hematuria, nausea, vomiting, and restlessness. Nursing care includes aggressive pain control, increased fluid intake unless contraindicated, ambulation, and straining all urine to capture the stone for analysis, which determines the prevention plan.

Benign Prostatic Hyperplasia

Enlargement of the prostate obstructs urine flow, producing hesitancy, weak stream, straining, dribbling, nocturia, and incomplete emptying with retention. After transurethral resection of the prostate, expect continuous bladder irrigation; the drainage should progress from pink to clear. Bright red drainage with clots, or a distended painful bladder with decreased output, suggests bleeding or obstruction and is reported immediately. Subtract irrigation volume from total output to determine true urine output.

Gastrointestinal and Hepatobiliary Disorders

Gastroesophageal Reflux and Peptic Ulcer Disease

Reflux produces heartburn, regurgitation, and sometimes a chronic cough or hoarseness. Teach the patient to avoid large meals, to remain upright for two to three hours after eating, to elevate the head of the bed, to lose weight if indicated, and to limit caffeine, alcohol, chocolate, peppermint, fatty foods, and tobacco.

Peptic ulcer disease is most often caused by Helicobacter pylori infection or by nonsteroidal anti-inflammatory drug use. Gastric ulcer pain typically worsens with eating, whereas duodenal ulcer pain typically improves with eating and returns two to three hours later or at night. Treatment includes proton pump inhibitors and, for H. pylori, combination antibiotic therapy.

Nursing application: sudden severe diffuse abdominal pain with a rigid board-like abdomen, absent bowel sounds, rebound tenderness, and tachycardia indicates perforation. Keep the patient nothing by mouth, notify the provider immediately, and prepare for surgery. Coffee-ground emesis or melena indicates upper gastrointestinal bleeding.

Inflammatory Bowel Disease

Ulcerative colitis affects the colon and rectum continuously with mucosal inflammation and produces frequent bloody diarrhea with mucus, tenesmus, and left lower quadrant cramping. Crohn disease can affect any part of the gastrointestinal tract in skip lesions with transmural inflammation and produces right lower quadrant pain, nonbloody diarrhea, fistulas, strictures, and malabsorption with nutritional deficiencies.

Nursing care during exacerbation includes bowel rest, monitoring for dehydration and electrolyte loss, a low-residue and low-fat diet as tolerated, and administration of aminosalicylates, corticosteroids, immunomodulators, or biologics. Toxic megacolon, marked by abdominal distention, fever, tachycardia, and a silent abdomen, is a surgical emergency.

Diverticular Disease

Diverticulosis is the presence of outpouchings in the colon wall and is prevented and managed with a high-fiber diet and fluids. Diverticulitis is inflammation or infection of those pouches, causing left lower quadrant pain, fever, and leukocytosis. During acute diverticulitis the diet is temporarily restricted to clear liquids or nothing by mouth with a low-fiber progression, and antibiotics are given; high fiber is resumed only after the acute episode resolves. Avoid enemas and laxatives that increase intraluminal pressure during the acute phase.

Appendicitis and Bowel Obstruction

Appendicitis produces periumbilical pain migrating to the right lower quadrant at McBurney point, rebound tenderness, anorexia, nausea, low-grade fever, and leukocytosis. Do not apply heat, do not give enemas or laxatives, and keep the patient nothing by mouth, because these measures can precipitate rupture. Sudden relief of pain followed by worsening diffuse pain suggests perforation with peritonitis.

Small bowel obstruction presents with colicky pain, profuse vomiting, and early high-pitched then absent bowel sounds; large bowel obstruction presents with marked distention and obstipation. Care includes nothing by mouth, nasogastric decompression, intravenous fluids with electrolyte replacement, and monitoring for strangulation.

Liver Disease

Cirrhosis is diffuse fibrosis with loss of hepatocyte function and portal hypertension. Findings include jaundice, ascites, splenomegaly, caput medusae, spider angiomas, palmar erythema, easy bruising and prolonged prothrombin time from impaired clotting factor synthesis, hypoalbuminemia with edema, and hepatic encephalopathy with asterixis and altered mentation from accumulated ammonia.

Nursing interventions: monitor abdominal girth and daily weight, restrict sodium, give lactulose titrated to produce two to three soft stools per day to eliminate ammonia, protect fragile skin, monitor for bleeding, avoid hepatotoxic drugs including acetaminophen beyond prescribed limits and alcohol, and assist with paracentesis, checking that the bladder is emptied first and monitoring for hypotension afterward.

Nursing application: esophageal varices are the most dangerous complication. Sudden hematemesis with hypotension and tachycardia is a life-threatening hemorrhage requiring immediate airway protection, large-bore intravenous access, volume resuscitation, and emergent endoscopy. Teach the patient to avoid straining, coughing forcefully, and heavy lifting.

Viral hepatitis A and E spread by the fecal-oral route; hepatitis B, C, and D spread by blood and body fluids. Hepatitis B has a vaccine and is a required occupational health protection for nurses; hepatitis C has no vaccine but has highly effective antiviral treatment.

Pancreatitis and Cholecystitis

Acute pancreatitis produces severe epigastric pain radiating to the back, often relieved somewhat by leaning forward or by a fetal position, with nausea, vomiting, fever, and abdominal distention. Serum lipase is the more specific marker; amylase also rises. Cullen sign (periumbilical bruising) and Grey Turner sign (flank bruising) indicate hemorrhagic pancreatitis. Hypocalcemia may develop. Care includes nothing by mouth with bowel rest, aggressive intravenous fluids, pain control, and abstinence from alcohol.

Cholecystitis produces right upper quadrant pain radiating to the right shoulder or scapula after a fatty meal, nausea, vomiting, and a positive Murphy sign. Obstruction of the bile duct adds jaundice, clay-colored stools, dark urine, and pruritus. Teach a low-fat diet and monitor after laparoscopic cholecystectomy for referred shoulder pain from residual carbon dioxide, which is relieved by ambulation.

Ostomy Care

An ileostomy produces liquid to pasty output that is high in enzymes and very irritating to skin, with substantial fluid and electrolyte loss. A colostomy produces progressively more formed stool the more distal it is. A healthy stoma is beefy red and moist; a pale, dusky, purple, or black stoma indicates compromised circulation and is reported immediately. Fit the appliance opening to the stoma with only a small margin to protect surrounding skin.

Endocrine Disorders

Diabetes Mellitus

Type 1 diabetes results from autoimmune beta cell destruction with absolute insulin deficiency and requires insulin. Type 2 diabetes results from insulin resistance with relative insulin deficiency and is managed with lifestyle change, oral agents, and often eventually insulin. Classic findings are polyuria, polydipsia, polyphagia, fatigue, blurred vision, and poor wound healing; weight loss is typical in type 1.

Hemoglobin A1c reflects average glycemic control over roughly the preceding two to three months, with a general adult target below seven percent, individualized by patient.

Insulin timing matters at the bedside. Rapid-acting insulin such as lispro or aspart begins to work within about fifteen minutes and must be given with food available. Short-acting regular insulin begins in about thirty minutes to an hour and is the only insulin routinely given intravenously. Intermediate-acting NPH peaks in roughly four to twelve hours, which is when hypoglycemia is most likely. Long-acting glargine and detemir are relatively peakless and are not mixed with other insulins. When mixing regular and NPH in one syringe, draw up regular first, remembering clear before cloudy.

Hypoglycemia presents with shakiness, diaphoresis, tachycardia, hunger, irritability, confusion, and eventually seizure and coma. In a conscious patient with a functional swallow, give fifteen grams of fast-acting carbohydrate, recheck the blood glucose in fifteen minutes, repeat if still low, and then follow with a protein-containing snack if a meal is not imminent. In an unconscious patient give intravenous dextrose or intramuscular or subcutaneous glucagon and never give anything by mouth.

Diabetic ketoacidosis occurs mainly in type 1 and presents with blood glucose usually above 250 mg/dL, arterial pH below 7.35 with low bicarbonate, positive serum and urine ketones, Kussmaul respirations, fruity breath odor, dehydration, and abdominal pain. Treatment order matters: intravenous isotonic fluid replacement comes first, then a regular insulin infusion, with continuous potassium monitoring. Serum potassium may look normal or high initially even though total body potassium is depleted, and insulin drives potassium into cells; insulin should be withheld and potassium replaced first if the serum potassium is below about 3.3 mEq/L. Dextrose is added to the fluids when the glucose falls to roughly 200 to 250 mg/dL to prevent hypoglycemia while the acidosis clears.

Hyperosmolar hyperglycemic state occurs mainly in type 2, with extremely high glucose often above 600 mg/dL, profound dehydration, and altered mental status, but without significant ketosis or acidosis because enough insulin remains to prevent lipolysis. Treatment centers on large-volume fluid resuscitation and insulin.

Nursing application: teach sick day rules. The patient continues taking insulin even when not eating well, checks glucose and ketones more frequently, maintains fluid and carbohydrate intake with liquids if solid food is not tolerated, and calls the provider for persistent vomiting, ketones, or glucose that remains uncontrolled.

Long-term complications include retinopathy, nephropathy, neuropathy, and accelerated atherosclerosis. Daily foot inspection, well-fitted shoes, never walking barefoot, cutting nails straight across, and testing water temperature with the hand or a thermometer rather than the foot are core teaching points.

Thyroid Disorders

Hyperthyroidism, most often Graves disease, produces weight loss despite increased appetite, heat intolerance, diaphoresis, tachycardia and palpitations, tremor, anxiety and insomnia, diarrhea, goiter, and exophthalmos. Treatment includes antithyroid drugs such as methimazole or propylthiouracil, beta blockers for symptom control, radioactive iodine, or thyroidectomy. Provide a cool, quiet environment and a high-calorie high-protein diet.

Thyroid storm is a life-threatening exacerbation with high fever, severe tachycardia or dysrhythmia, hypertension, agitation, and delirium, often triggered by infection, surgery, or stress. It requires immediate cooling, beta blockade, antithyroid medication, and intensive monitoring.

Hypothyroidism produces fatigue, cold intolerance, weight gain, bradycardia, dry coarse skin and hair loss, constipation, depression, and slowed mentation. Levothyroxine is taken in the morning on an empty stomach, at least thirty minutes to an hour before food, and separated from calcium and iron supplements, which impair absorption. It is a lifelong therapy. Myxedema coma is the severe decompensated form with hypothermia, hypoventilation, hypotension, hyponatremia, and stupor.

Nursing application: after thyroidectomy the priorities are airway and hemorrhage. Keep a tracheostomy tray and suction at the bedside, check for bleeding behind the neck and on the pillow, support the head and neck when moving, and monitor voice quality for laryngeal nerve injury. Watch for hypocalcemia from inadvertent parathyroid injury, which presents with tingling around the mouth and in the fingertips and positive Chvostek and Trousseau signs.

Adrenal Disorders

Addison disease is adrenocortical insufficiency, producing fatigue, weakness, anorexia and weight loss, hypotension, salt craving, hyperpigmentation, hyponatremia, hyperkalemia, hypoglycemia, and hypovolemia. Addisonian crisis is precipitated by stress, infection, or abrupt withdrawal of corticosteroids and presents with profound hypotension and shock; treatment is immediate intravenous fluids with sodium and glucose and intravenous hydrocortisone.

Cushing syndrome results from cortisol excess, producing truncal obesity with thin extremities, a moon face and buffalo hump, purple striae, thin fragile skin with easy bruising, hyperglycemia, hypertension, hypokalemia, osteoporosis, muscle wasting, and impaired immunity.

Nursing application: patients on long-term corticosteroids never stop them abruptly, need increased doses during physiologic stress, should take them with food, and require monitoring for hyperglycemia, infection, and gastrointestinal bleeding.

Pheochromocytoma, a catecholamine-secreting tumor, causes severe episodic hypertension with headache, palpitations, and diaphoresis. Do not palpate the abdomen, because palpation can trigger a hypertensive crisis.

Pituitary and Water Balance Disorders

Syndrome of inappropriate antidiuretic hormone causes water retention with dilutional hyponatremia, concentrated urine with high specific gravity, low serum osmolality, weight gain without edema, and neurologic changes. Management is fluid restriction, sodium monitoring, and sometimes hypertonic saline for severe symptomatic hyponatremia, corrected slowly.

Diabetes insipidus is the mirror image: deficient antidiuretic hormone causes massive output of very dilute urine with low specific gravity, intense thirst, hypernatremia, and risk of hypovolemic shock. Management is fluid replacement and desmopressin.

Neurologic Disorders

Increased Intracranial Pressure

The skull is a fixed space, so any increase in brain tissue, blood, or cerebrospinal fluid raises pressure. The earliest and most sensitive sign of increased intracranial pressure is a change in level of consciousness, including restlessness, irritability, or confusion. Additional findings are headache, vomiting that may be projectile, pupillary changes with a sluggish or fixed and dilated pupil, and papilledema.

Cushing triad is a late and ominous sign of impending herniation: rising systolic blood pressure with a widening pulse pressure, bradycardia, and irregular respirations.

Nursing interventions: elevate the head of the bed about thirty degrees unless contraindicated, keep the head in neutral midline alignment to promote venous drainage, avoid hip flexion and neck flexion, prevent Valsalva by treating constipation and avoiding straining, cluster care to limit stimulation, keep suctioning brief and preoxygenate, control fever and pain, and administer osmotic diuretics such as mannitol as ordered. Avoid hypotonic fluids.

Stroke

Ischemic stroke results from thrombosis or embolism and accounts for most strokes; hemorrhagic stroke results from rupture of a vessel, often from hypertension or aneurysm. Findings include sudden unilateral weakness or numbness, facial droop, speech difficulty, vision loss, and sudden severe headache, which is more characteristic of hemorrhage. A subarachnoid hemorrhage classically presents as the worst headache of the patient's life with nuchal rigidity.

The first diagnostic priority is a noncontrast computed tomography scan to distinguish ischemic from hemorrhagic stroke, because thrombolytic therapy is life-saving in one and lethal in the other. Intravenous alteplase is given for eligible ischemic stroke patients generally within three hours and up to four and a half hours from the time the patient was last known well.

Left hemisphere stroke typically produces right-sided weakness, aphasia, and slow cautious behavior. Right hemisphere stroke typically produces left-sided weakness, unilateral neglect, impulsivity, and poor safety judgment.

Nursing application: keep the patient nothing by mouth until a swallow screen is passed, because aspiration pneumonia is a leading complication. When feeding is resumed, position upright at ninety degrees, use thickened liquids if prescribed, place food in the unaffected side of the mouth, and check for pocketing. Approach a patient with neglect from the unaffected side initially for safety, then teach scanning toward the neglected side.

Seizures

During a seizure, protect the patient rather than restrain the patient: stay with the patient, ease them to the floor or lower the bed, turn the head or body to the side to protect the airway, remove nearby objects, loosen restrictive clothing, pad the side rails, and time the event. Never insert anything into the mouth and never restrain limbs. Afterward assess airway, vital signs, neurologic status, and injuries, and allow the patient to rest through the postictal period.

Status epilepticus is continuous or repeated seizure activity without recovery and is a medical emergency treated with airway support, oxygen, and intravenous benzodiazepines followed by a longer-acting anticonvulsant.

Phenytoin teaching includes meticulous oral hygiene because of gingival hyperplasia, avoiding abrupt discontinuation, and awareness of numerous drug interactions. Phenytoin is mixed only with normal saline, never with dextrose solutions, which cause precipitation.

Neuromuscular and Degenerative Disorders

Myasthenia gravis is an autoimmune attack on acetylcholine receptors, producing descending weakness that worsens with activity and improves with rest, ptosis, diplopia, difficulty chewing and swallowing, and respiratory muscle weakness. Myasthenic crisis is undermedication or a trigger causing severe weakness and respiratory failure; cholinergic crisis is overmedication with anticholinesterase drugs and adds salivation, lacrimation, diarrhea, and muscle fasciculations. Both threaten the airway, so respiratory support is the immediate priority in either case.

Guillain-Barre syndrome produces ascending symmetric weakness and paralysis, often after a viral or gastrointestinal illness. The nursing priority is serial monitoring of respiratory status, particularly vital capacity and negative inspiratory force, because ascending paralysis can reach the diaphragm. Recovery is usually descending and gradual.

Multiple sclerosis is demyelination in the central nervous system producing variable fatigue, visual disturbance, weakness, spasticity, paresthesia, and bladder dysfunction with relapses and remissions. Teach avoidance of heat, which temporarily worsens symptoms, along with energy conservation and fall prevention.

Parkinson disease results from dopamine deficiency in the basal ganglia and produces resting tremor, cogwheel rigidity, bradykinesia, a shuffling festinating gait, masked facies, and postural instability. Teach the patient to consciously lift the feet, to use a wide stance, to allow extra time, and to eat soft, high-calorie foods safely.

Spinal Cord Injury

Immediately after injury, spinal shock produces flaccid paralysis, loss of reflexes, and loss of sensation below the level of injury. Injuries at or above C4 threaten diaphragm function and may require ventilatory support.

Nursing application: autonomic dysreflexia is an emergency in patients with injury at or above the sixth thoracic vertebra. A noxious stimulus below the injury level, most commonly a distended bladder or impacted bowel, triggers severe hypertension with a pounding headache, bradycardia, flushing and sweating above the injury, and pallor and coolness below it. Act in this order: place the patient in a sitting position immediately to lower blood pressure, loosen constrictive clothing, then find and remove the stimulus by checking for kinked catheter tubing or bladder distention and then for impaction, and notify the provider. Untreated, it causes stroke, seizure, or death.

Musculoskeletal Disorders

Fractures and Immobilization

Findings include pain, deformity, swelling, crepitus, loss of function, and ecchymosis. Neurovascular assessment distal to any injury, cast, or splint is performed routinely and includes pain, pallor, pulse, paresthesia, paralysis, and poikilothermia, with temperature, capillary refill, and movement documented.

Cast care: elevate the extremity above heart level for the first day or two, apply ice as ordered, handle a wet plaster cast with palms rather than fingertips, allow air drying without covering, never insert objects under the cast to scratch, and keep the cast dry. Report increasing pain, numbness, foul odor, drainage, or a hot spot.

Traction: maintain continuous pull with weights hanging freely and off the floor, keep the patient in proper alignment, do not remove weights without an order, and provide pin site care for skeletal traction while monitoring for infection.

Nursing application: compartment syndrome is caused by increased pressure within a fascial compartment that compromises circulation. The hallmark is pain out of proportion to the injury that is unrelieved by opioids and increases with passive stretch, along with paresthesia and tightness. Pulselessness is a very late finding, so waiting for a lost pulse is a serious error. Report immediately, elevate no higher than heart level, and prepare for possible fasciotomy. Do not elevate above the heart, because that reduces arterial perfusion.

Fat embolism syndrome typically occurs twenty-four to seventy-two hours after fracture of a long bone or pelvis and presents with sudden dyspnea, hypoxemia, tachycardia, confusion, and a petechial rash over the chest, neck, and axillae. Support oxygenation and notify the provider urgently.

Joint Replacement

After total hip arthroplasty with a posterior approach, the patient avoids flexing the hip beyond ninety degrees, avoids crossing the legs or adducting past midline, and avoids internal rotation. Use an abduction pillow, a raised toilet seat, a high chair with arms, and a reacher, and do not bend to put on socks or shoes. Report sudden severe pain, shortening with external rotation of the affected leg, or a popping sensation, which suggest dislocation.

After total knee arthroplasty, encourage continuous passive motion if ordered, early ambulation, and quadriceps strengthening, and control pain before therapy so the patient can participate.

For both, venous thromboembolism prophylaxis and infection monitoring are central nursing responsibilities.

Chronic Bone and Joint Disease

Osteoarthritis is degenerative cartilage wear producing asymmetric joint pain that worsens with use and improves with rest, with morning stiffness typically lasting under thirty minutes and Heberden and Bouchard nodes. Rheumatoid arthritis is a systemic autoimmune disease producing symmetric joint inflammation with morning stiffness lasting more than an hour, fatigue, low-grade fever, and eventual deformity. Heat helps rheumatoid stiffness before activity; cold helps acute inflammation and swelling.

Osteoporosis is loss of bone density, often silent until a fracture occurs, with vertebral compression fractures, kyphosis, and height loss. Teach adequate calcium and vitamin D, weight-bearing exercise, smoking and alcohol reduction, and fall prevention. Bisphosphonates are taken in the morning on an empty stomach with a full glass of plain water, and the patient must remain upright for at least thirty minutes to prevent esophageal erosion.

Gout is uric acid crystal deposition producing sudden severe pain, redness, and swelling, classically in the great toe. Teach hydration, weight management, and avoidance of purine-rich foods such as organ meats, sardines, anchovies, and beer.

Hematologic and Immune Disorders

Anemias

Iron deficiency anemia produces fatigue, pallor, and a microcytic hypochromic picture. Teach that oral iron is best absorbed on an empty stomach and with a source of vitamin C, that it causes dark stools and constipation, and that liquid forms are taken through a straw to protect the teeth.

Pernicious anemia results from lack of intrinsic factor with vitamin B12 malabsorption and adds neurologic findings such as paresthesia, ataxia, and impaired proprioception. It requires lifelong parenteral or high-dose supplementation, because oral standard replacement alone does not correct the absorption defect.

Sickle cell disease causes red cells to sickle under hypoxia, dehydration, infection, cold exposure, acidosis, and stress, occluding vessels and causing vaso-occlusive crisis with severe pain, swelling, and organ ischemia. Nursing care in crisis is hydration, oxygen, aggressive analgesia including opioids, warmth, and rest. Never apply cold, which promotes further sickling, and avoid constrictive measures.

Neutropenia and Bleeding Precautions

Neutropenic precautions apply when the absolute neutrophil count is low. Practice strict hand hygiene, screen visitors for illness, avoid fresh flowers and standing water, avoid raw or undercooked foods per facility policy, avoid invasive procedures including rectal temperatures and suppositories, and treat fever as an emergency, because it may be the only sign of infection when the inflammatory response is blunted.

Bleeding precautions for thrombocytopenia include a soft toothbrush, an electric razor, no rectal procedures, no intramuscular injections when avoidable, prolonged pressure after venipuncture, fall prevention, and avoidance of aspirin and nonsteroidal anti-inflammatory drugs.

Transfusion Reactions

Verify the blood product and the patient with two qualified individuals per policy, use normal saline only as the compatible solution, use appropriate filtered tubing, start slowly, and remain with the patient for the first fifteen minutes, when most severe reactions occur. Take a baseline set of vital signs and repeat per policy.

If any reaction is suspected, stop the transfusion immediately, keep the line open with normal saline using new tubing, take vital signs, and notify the provider and the blood bank. Acute hemolytic reaction presents with fever, chills, low back or flank pain, hypotension, dark urine, and a sense of doom. Febrile nonhemolytic reaction presents with fever and chills. Allergic reaction presents with hives and itching, and anaphylaxis adds wheezing and hypotension. Transfusion-associated circulatory overload presents with dyspnea, crackles, hypertension, and distended neck veins.

Human Immunodeficiency Virus

Progressive depletion of CD4 T lymphocytes produces immunodeficiency and opportunistic infection. Antiretroviral therapy adherence is critical, because inconsistent dosing promotes resistance. Standard precautions protect the nurse; the patient may need protective measures against infection depending on the CD4 count. Report fever, new cough, oral lesions, changes in vision, headache, or unexplained weight loss.

Perioperative and Postoperative Nursing

Preoperative Care

Verify that informed consent is signed, that the patient understands the procedure, and that the surgeon, not the nurse, obtained the consent; the nurse witnesses the signature and confirms understanding. Confirm allergies, current medications including anticoagulants, herbal products, and diabetes agents, the nothing by mouth status, and the removal of jewelry, dentures, and prostheses per policy. Verify the site marking and participate in the surgical time-out.

Preoperative teaching that reduces complications includes coughing and deep breathing, incentive spirometry, splinting the incision with a pillow, leg exercises, early ambulation, and how to rate and report pain.

Postoperative Priorities

Immediate priorities are airway and breathing, then circulation, then level of consciousness, then pain, then surgical site and drains, then output.

Monitor for the classic complications by timing. Atelectasis and pneumonia often explain fever in the first forty-eight hours, and the response is pulmonary hygiene and ambulation, not antibiotics alone. Urinary retention appears in the first day. Wound infection typically appears after the third to fifth day with fever, purulent drainage, increasing pain, and erythema. Venous thromboembolism can occur at any point and is prevented by early ambulation, compression devices, and prophylactic anticoagulation. Paralytic ileus presents with absent bowel sounds, distention, and no passage of flatus.

Nursing application: wound dehiscence is separation of the wound layers, and evisceration is protrusion of viscera through the opening. If evisceration occurs, cover the organs with sterile gauze moistened with sterile normal saline, place the patient in low Fowler position with the knees slightly bent to reduce abdominal tension, keep the patient nothing by mouth, monitor for shock, stay with the patient, and notify the surgeon immediately. Do not attempt to reinsert the organs.

Shock, Sepsis, and Burns

Shock

Shock is inadequate tissue perfusion. Hypovolemic shock follows hemorrhage or fluid loss; cardiogenic shock follows pump failure such as large myocardial infarction; distributive shock includes septic, anaphylactic, and neurogenic types; obstructive shock includes tension pneumothorax, cardiac tamponade, and massive pulmonary embolism.

Early compensated findings are restlessness and anxiety, tachycardia, tachypnea, cool clammy skin, and a narrowing pulse pressure with a still-normal systolic pressure. Hypotension is a later finding, and decreased urine output below about thirty milliliters per hour is an early and reliable indicator of poor perfusion. Neurogenic and early septic shock are exceptions to the cool skin rule, presenting with warm, dry, or flushed skin, and neurogenic shock characteristically causes bradycardia rather than tachycardia.

Anaphylaxis requires immediate intramuscular epinephrine, airway support, oxygen, and rapid fluids, with antihistamines and corticosteroids as adjuncts, not as first-line treatment.

Sepsis

Suspect sepsis with infection plus fever or hypothermia, tachycardia, tachypnea, altered mentation, and hypotension. Obtain blood cultures before administering antibiotics when this does not delay treatment, give broad-spectrum antibiotics within the first hour, give rapid crystalloid resuscitation, measure serum lactate and remeasure it, and add vasopressors if hypotension persists after fluids. Time to antibiotics drives survival, so any delay is reported and escalated.

Burns

Estimate extent with the rule of nines in adults: head and neck nine percent, each arm nine percent, each leg eighteen percent, anterior trunk eighteen percent, posterior trunk eighteen percent, and perineum one percent.

The first priority in any burn is the airway. Facial burns, singed nasal hairs, soot in the mouth or sputum, hoarseness, or stridor signal inhalation injury and impending airway obstruction; secure the airway early, before edema makes intubation impossible. Carbon monoxide poisoning is treated with one hundred percent oxygen, and pulse oximetry is unreliable in that setting.

Fluid resuscitation in the first twenty-four hours commonly uses the Parkland formula, four milliliters of lactated Ringer solution per kilogram per percent of total body surface area burned, with half of the total given in the first eight hours calculated from the time of injury, not from the time of arrival, and the remaining half over the following sixteen hours. Titrate to urine output of roughly thirty to fifty milliliters per hour in adults.

The emergent phase risks hypovolemia and hyperkalemia as fluid and potassium shift out of cells and into the interstitium. The fluid remobilization phase that follows risks hypervolemia and hypokalemia. Circumferential burns can cause compartment syndrome and may require escharotomy. Nutrition requirements are very high in protein and calories, and infection is the leading cause of later death.

Pain Management and Safety

Pain is what the patient says it is. Use a consistent scale, accept the patient's self-report, reassess after every intervention within the medication's expected onset, and document both the score and the functional effect.

Opioid monitoring focuses on respiratory depression, which is preceded by sedation. A rising sedation score is the earliest warning; naloxone reverses opioid effect but also reverses analgesia and can precipitate withdrawal. Constipation does not resolve with tolerance, so a bowel regimen is started with the opioid.

Nursing application: with patient-controlled analgesia, only the patient presses the button. Family members pressing it for a sleeping patient removes the built-in safety of a sedated patient being unable to self-dose, and this must be taught explicitly to visitors.

Nonpharmacologic measures including repositioning, heat or cold as appropriate, distraction, relaxation, and music are used alongside medication, not instead of appropriate analgesia.

Infection Prevention

Standard precautions apply to every patient regardless of diagnosis and include hand hygiene, gloves for contact with blood and body fluids, and personal protective equipment based on anticipated exposure.

Contact precautions apply to organisms such as Clostridioides difficile, multidrug-resistant organisms, scabies, and draining wounds, and require gown and gloves. For C. difficile, use soap and water for hand hygiene, because alcohol-based rub does not kill spores.

Droplet precautions apply to influenza, pertussis, meningococcal disease, and mumps, and require a surgical mask within about three to six feet, with a private room preferred.

Airborne precautions apply to tuberculosis, measles, and varicella and disseminated zoster, and require a negative pressure room and a fitted N95 respirator or higher.

Nursing application: when donning, the general sequence is gown, mask or respirator, goggles or face shield, then gloves. When doffing, gloves come off first because they are most contaminated, then goggles, then gown, then mask, with hand hygiene performed at the end and whenever hands become contaminated during the process.

Older Adult Considerations

Aging changes alter presentation. Reduced thirst sensation and lower total body water raise dehydration risk. Reduced kidney and liver function prolong drug effects and raise toxicity risk, so start low and go slow. Reduced baroreceptor sensitivity increases orthostatic hypotension and falls. Blunted febrile response means a normal temperature does not rule out infection, and new confusion, functional decline, incontinence, or falling may be the only signs of an acute illness.

Delirium is acute, fluctuating, and reversible, and it is a symptom of an underlying problem such as infection, hypoxia, medication, pain, or electrolyte imbalance. Dementia is chronic and progressive. Treating new-onset confusion as expected aging is a serious and common error.

High-Yield Priority Reminders

Report immediately: a new or worsening change in level of consciousness; new chest pain; sudden dyspnea or hypoxemia; a rigid board-like abdomen; pain unrelieved by opioids after orthopedic injury; absent or diminished pulses in an extremity; a dusky or black stoma; cloudy peritoneal dialysate; hypertension with pounding headache in a patient with a spinal cord injury above the sixth thoracic vertebra; any suspected transfusion reaction; and any sign of bleeding in an anticoagulated patient.

Assess before acting when the patient is stable and the data would change the action. Act first when the airway, breathing, circulation, or life is immediately threatened.

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