Medical-Surgical Nursing
Medical-surgical items dominate the paper. They rarely ask for a definition; they ask you to prioritise, to interpret a trend, or to predict the next complication. The winning option is almost always the one that secures airway, breathing or circulation before anything else, and that reassesses after the intervention.
Prioritisation and recognition of deterioration
- Work through ABCDE: airway, breathing, circulation, disability, exposure. Treat the most immediately life-threatening problem first, regardless of the order it appears in the stem.
- Deterioration is a trend, not a single value. A rising respiratory rate and falling urine output precede cardiac arrest by hours.
- Sepsis: infection plus organ dysfunction. qSOFA uses respiratory rate 22 or above, altered mentation, and systolic pressure 100 or below. Escalate for senior review and antibiotics within one hour of recognising septic shock.
- Hypovolaemic shock after surgery: tachycardia, narrow pulse pressure, cool peripheries, urine output below 0.5 mL per kg per hour, and metabolic acidosis.
Specific conditions
- Acute coronary syndrome: chest pain with diaphoresis. Give aspirin 300 mg chewed, sublingual glyceryl trinitrate, analgesia, oxygen only if saturation is below 94 percent, and obtain a 12-lead ECG within 10 minutes while monitoring for arrhythmia.
- Diabetic ketoacidosis: glucose usually above 11 mmol/L, ketones present, pH below 7.3, bicarbonate below 18, Kussmaul breathing. Potassium may look normal or high despite total body depletion, so replace it as insulin drives it intracellularly.
- Hyperkalaemia with ECG changes: calcium gluconate first to stabilise the myocardium, then insulin-dextrose and nebulised salbutamol to shift potassium into cells.
Worked example
Day 2 after emergency laparotomy: pulse 118, blood pressure 96/70 when usual is 130/80, respiratory rate 24, temperature 38.4 degrees Celsius, urine 15 mL in the hour, cool peripheries, new confusion. What is the priority? Reasoning: this is not just pain. Tachycardia, narrow pulse pressure, oliguria and new confusion indicate hypoperfusion, and the fever makes sepsis more likely than simple hypovolaemia, though both may coexist. Priority actions are ABCDE, oxygen to keep saturation at 94 percent or above, two large-bore cannulae, a prescribed fluid challenge, blood cultures before antibiotics, lactate measurement, hourly urine measurement, and urgent surgical review. Giving an antipyretic and waiting is wrong.
Traps that cost marks
- Attributing new confusion in an older patient to age rather than hypoxia, sepsis or hypoperfusion.
- Withholding analgesia in an acute abdomen for fear of masking signs; analgesia does not obscure diagnosis.
- Giving high-flow oxygen to a COPD patient with carbon dioxide retention risk instead of targeting 88 to 92 percent.