STAT Stitch Deep Dive Podcast Beyond The Bedside

STAT Stitch Deep Dive Podcast Beyond The Bedside

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MEDSURG | Part 2 Neuro Disorders

🧠 HIGH-YIELD NEURO NURSING STUDY GUIDE ⚡ This guide hits the 20% of neuro content that gives you 80% of your clinical edge—rapid, focused, and straight to what matters in exams and practice. 🩸 Trauma & ICP Mild TBI: GCS ≥13, minor capillary bleed. Mod/Severe TBI: GCS 9–12/≤8. Watch for Cushing’s Triad 🚨 (↑BP, ↓HR, irregular resp). ➤ Manage w/ mannitol or hypertonic saline, maintain airway, avoid hypoxia. Epidural Hematoma: ⚠️ Lucid interval, then coma. Ipsilateral dilated pupil → immediate surgery. Basilar Skull Fx: Raccoon eyes, Battle sign, CSF leak. Prevent infection w/ IV ABX. 🧬 Cerebrovascular Emergencies Ischemic Stroke: Sudden neuro deficit. “Time = Brain.” ➤ rtPA within 4.5 h 🕐, thrombectomy up to 24 h if eligible. ➤ Maintain BP ≤185/110 mmHg if thrombolytics planned. Hemorrhagic Stroke: Often hypertensive. High early mortality. Manage ICP, avoid anticoags. Dysphagia Precaution: Keep NPO until swallow eval—aspiration kills faster than stroke. 🦠 CNS Infections Bacterial Meningitis: Fever + nuchal rigidity + petechial rash 🚨 ➤ Draw cultures → start IV ABX + dexamethasone STAT. Viral Encephalitis (HSV): Hallucinations, confusion → IV Acyclovir immediately. ⚡ Seizures Tonic-Clonic: Protect airway, pad rails, do NOT restrain or put anything in mouth. ➤ Document onset, duration, postictal phase. Status Epilepticus: ≥5 min seizure → IV/IM Lorazepam or Midazolam STAT. Watch for aspiration, cardiac arrest, cerebral edema. Todd Paresis: Temporary weakness post-seizure (not stroke!). 💊 Anticonvulsants Phenytoin: Check levels, CBC, LFTs. Gingival hyperplasia → oral care. Carbamazepine: No grapefruit juice. Risk: dizziness, rash, bleeding. Valproic Acid: ⚠️ Liver toxicity, bleeding, pregnancy danger. 🧍‍♂️ Chronic Neuro Disorders Parkinson’s: ↓Dopamine. Tremor, rigidity, bradykinesia. ➤ Carbidopa/Levodopa = gold standard. Teach “on/off” periods. ➤ Avoid excess Vit B6 & tyramine (if on MAO-B inhibitors). Myasthenia Gravis: Weakness worse w/ exertion. ➤ Give anticholinesterase meds on time, monitor resp status. Multiple Sclerosis: Demyelinating autoimmune flare-ups. ➤ Avoid heat, infection, fatigue. Corticosteroids for exacerbations. 💣 Red-Flag Drugs & Contraindications Triptans: 🚫 in CAD, HTN, PVD. Antiseizure meds: Never stop abruptly → rebound SE. Anticholinesterase OD: Cholinergic crisis (drooling, bradycardia, weakness).

MEDSURG | Musculoskeletal Assessment

🦴 I. Impaired Bone Integrity & Structure Core Concept: Bone = dynamic tissue of collagen (organic) + calcium/phosphate (inorganic). Remodeling = resorption (osteoclasts) + formation (osteoblasts). Imbalance → bone weakness, ↓ density, ↑ fracture risk. ⚕️ Common Meds & Nursing Cues: Ca & Vit D: Maintain mineral balance. Monitor diet/nutrition. Opioids/NSAIDs: Pain control. Watch for GI bleed (NSAIDs), resp depression (opioids). 👩‍⚕️ Interprofessional Care: MD: Orders X-ray, DEXA, bone scans. RN: Pre/post-procedure care, pain/mobility checks. Radiology Tech: Verify pregnancy, renal function (contrast). Dietitian: Optimize Ca, Vit D, protein intake. 🚨 Manifestations: Acute: Loss of function, severe pain → possible fracture or neurovascular compromise. Labs: ↑ Alk Phos (30–120 u/L) = bone formation or cancer. Abnormal Ca (9.0–10.5 mg/dL) = metabolic issue. Chronic: Kyphosis, lordosis. 💉 Nursing Mgmt: Bone Scan: Stay still; hydrate post-scan. CT/Myelogram: Check iodine allergy, renal fx, hold metformin; explain flushing sensation. Fall Risk: Use assistive devices, declutter, proper lighting. 🧠 Quick Cues: ↑ Alk Phos = bone healing. Always assess allergies/meds before contrast. Bone = collagen + Ca + phosphate; remodeling = key. DEXA = Bone Density Test. 💪 II. Impaired Joint Mobility & Muscle Function Core Concept: Muscles → tendons → bones via ligaments/joints. Joints = synovial sacs with fluid for smooth movement. Dysfunction (OA, RA, dystrophy, trauma) → stiffness, atrophy, contracture. ⚕️ Common Meds: Corticosteroids: ↓ inflammation; monitor for HTN, hyperglycemia, osteoporosis. Muscle Relaxants: ↓ spasms; watch for sedation, fall risk, driving caution. 🤝 Interprofessional Care: RN: Pain mgmt, coordinate PT/OT, support ADLs. PT: ROM, strength; medicate before sessions. OT: Teach adaptive methods for independence. RT: Support if scoliosis or dystrophy impairs breathing. 🚨 Manifestations: Critical: Sudden ↓ pulse, pale/cool limb = neurovascular emergency. Severe: Weakness (use 0–5 scale), crepitus, ↑ CK (20–200 u/L = muscle injury), ↑ CRP (<1.0 mg/dL normal = inflammation). 💉 Nursing Mgmt: Pain: Assess 0–10; medicate pre-activity; add heat/cold. Immobility: Measure ROM (goniometer), grade strength, rest when fatigued, teach body mechanics. Sleep/Fatigue: Optimize environment; control pain before bed. 🧠 Quick Cues: 5/5 = full muscle strength. ↑ CK = muscle damage. EMG: No caffeine 2–3 h before; no lotions. Bursae: Cushions reduce friction near joints. Chronic pain affects self-image & roles.

MEDSURG | Ortho Trauma & More

🩺 Med-Surg Review: Musculoskeletal Trauma (High-Yield, <2800 chars) 1) Acute Soft-Tissue Injuries — Sprain/Strain/Dislocation • Sprain: ligament tear/stretch. • Strain: muscle/tendon tear/stretch. • Dislocation: complete joint surface separation → risk neurovascular injury & avascular necrosis. Meds: NSAIDs (GI bleed risk), analgesics (opioid constipation/resp depression). Team: MD (X-ray, reduction/cast or surgery); RN: RICE (Rest-Ice-Compression-Elevation), immobilize; PT: gradual ROM/strength; Dietitian: Ca/Vit D. Critical signs: obvious deformity (dislocation), neurovascular compromise. Common: pain, swelling, bruising, ↓ function. RN priorities: • Neurovascular checks distal: color, temp, cap refill, pulses, sensation, motor. • Immobilize as found; do NOT reduce. • Ice 20–30 min on, 20 off for 24–48 h; elevate above heart. Quick cues: Neurovascular first; immobilize; RICE; watch for avascular necrosis (hip/shoulder). 2) Fracture Complications — Compartment Syndrome (CS) & Fat Embolism Syndrome (FES) A) Compartment Syndrome Patho: ↑ pressure in closed muscle space → ↓ perfusion → ischemia/necrosis (4–8 h) → amputation risk. Key sign: Pain out of proportion & with passive stretch, not relieved by opioids. Six Ps: Pain*, Paresthesia*, Pallor, Paralysis (late), Pulselessness (late), Pressure (*=early/critical). RN actions: Hourly neurovascular checks; do NOT elevate above heart; keep level; loosen/bivalve cast per order; notify MD STAT; prep for fasciotomy. Quick: Pain unrelieved by opioids = red flag. B) Fat Embolism Syndrome (24–48 h post long-bone/pelvis fractures) Triad: Resp distress (tachypnea, hypoxemia, chest pain, cyanosis), Neuro changes (confusion, HA), Petechiae(neck/chest/axilla/conjunctiva). Mgmt: Prompt immobilization of fracture; O2/ventilation to keep PaO₂ >60; IV fluids; consider steroids (controversial). Team: MD (airway/hemodynamics, VTE ppx), RN (monitor resp/neuro, fluids), RT (O₂/vent). Quick: Timing 24–48 h; long bones; triad present → escalate. 3) Total Hip Arthroplasty (THA) / Hip Fracture Risks: VTE (DVT/PE); post-op dislocation (sudden severe pain, lump buttock, limb shortening, external rotation). Meds: Anticoagulants (LMWH, Xa-inhibitors, warfarin/INR, aspirin) → bleed watch; opioids (constipation); pre-op antibiotics. RN: VTE ppx (TED/SCD, ankle pumps), early ambulation, pain control, bowel regimen. Hip precautions: No flexion >90°, no adduction/crossing legs, no internal rotation; keep abduction wedge, neutral rotation; raised chairs/toilet. Quick: Positioning + precautions prevent dislocation; teach DVT/PE symptoms.

MEDSURG | Musculoskeletal Problems

🦴 Medical–Surgical Exam Review Guide: Musculoskeletal Problems 1️⃣ Osteomyelitis (Bone Infection) Pathophysiology: Infection of bone, bone marrow, and soft tissue (usually Staphylococcus aureus). Microbes enter via hematogenous spread (common in children, IV drug users, diabetics) or direct inoculation (open wounds, surgery, prosthetic joints). Inflammation → pus → ↑ intramedullary pressure → ↓ perfusion → ischemia → bone necrosis (sequestrum) surrounded by new bone (involucrum). Antibiotics struggle to reach the necrotic core. High-Yield Manifestations PriorityKey FindingsNotes🔴 HighConstant, worsening painNot relieved by rest; hallmark finding.🔴 HighFever, night sweats, restlessnessMay progress to sepsis.🟡 ModerateLocal swelling, warmth, tendernessReduced mobility near site.🟢 ChronicDrainage from sinus tractIndicates chronic infection. Medications & Management Drug/ClassKey EffectNursing FocusIV antibiotics (Oxacillin, Nafcillin, Vancomycin, Linezolid, Ciprofloxacin)Bactericidal; 4–6+ weeksUse CVAD, monitor for nephrotoxicity/ototoxicity (esp. Vanco), monitor ESR & CRP.Oral antibiotics (Ciprofloxacin, Levofloxacin)Step-down therapyMonitor for tendon rupture (fluoroquinolones).NSAIDs, opioids, muscle relaxantsPain reliefAdminister ATC; handle limb gently. Nursing Priorities 🚨 Prevent sepsis: Monitor temp, WBC, ESR, drainage. 💉 CVAD care: Maintain sterility; teach home IV use. 🦵 Immobilize limb: Prevent pathologic fracture. 🧼 Wound care: Sterile technique, NPWT if ordered. 📚 Education: Complete antibiotic course, report toxicity, ROM for unaffected joints. Quick Review NCLEX Alert: Risk for sepsis & pathologic fracture. Hallmark: Constant, unrelieved bone pain. Core Therapy: Long-term IV antibiotics. Monitor Labs: ESR, CRP trends. 2️⃣ Intervertebral Disc Disease (IDD) / Spinal Surgery Pathophysiology: Disc degeneration (DDD) or herniation → nucleus pulposus protrudes through annulus fibrosis → compresses spinal nerve root (radiculopathy) or spinal cord (myelopathy). Red-Flag Manifestations PriorityClinical FeatureDetails🚨 EMERGENCYCauda Equina Syndrome (CES)Severe low back pain, saddle anesthesia, new bowel/bladder dysfunction → surgical emergency.🔴 HighRadicular pain (sciatica)Radiates down leg, worsens w/ cough or strain.🟡 ModeratePositive straight-leg raisePain reproduced on raising affected leg. Conservative & Surgical Management Drugs: NSAIDs, acetaminophen, muscle relaxants (Cyclobenzaprine, Diazepam), epidural corticosteroid injections. Surgery: Laminectomy, discectomy, spinal fusion. Post-Op Nursing Care ProblemAssessInterveneEducate🧠 Neuro declineMotor, sensory, circulation Q2–4hReport new weakness or paresthesiaReport any numbness or new weakness.💧 CSF leakClear/yellow drainage, HAKeep flat, notify HCPReport severe HA or drainage.🚽 Bowel/bladderSounds, distention, voidingCath if ordered, stool softenersReport retention or constipation.🛏️ AlignmentPosition, painLogroll, avoid twistingAvoid lifting, bending, long sitting.

MEDSURG | Connective Tissue + Arthritis and More

🧑‍⚕️ Med-Surg Exam Guide: Rheumatic Disorders 1) 🦴 Osteoarthritis (OA) Patho: Local, non-systemic wear of articular cartilage → osteophytes; brief AM stiffness (<30 min). Meds: Acetaminophen → pain (watch max dose). NSAIDs/COX-2 → pain/↑GI & CV risk; take w/ food. Intra-articular steroids → short-term relief; rest joint x1 wk. Topicals (capsaicin/diclofenac) → regular use; avoid heat/sun. Team: HCP (rx ± surgery), RN (education, safety), PT/OT (ROM, devices), RD (weight loss). Key sx: Activity pain ➜ rest relief, crepitus, ↓ROM, Heberden/Bouchard nodes, deformity (varus/valgus). RN priorities: NSAID safety, heat for stiffness/cold if inflamed, joint protection, weight mgmt. OA Quick Hits: Asymmetric weight-bearing joints; XR: joint-space narrowing; synovial fluid clear. 2) 🔥 Rheumatoid Arthritis (RA) Patho: Systemic autoimmune synovitis → pannus → erosions; symmetric small joints; AM stiffness >60 min; flares/remission. Meds: DMARDs (MTX, SSZ, LEF, HCQ) → slow disease; labs; teratogenic (MTX/LEF); eye exams (HCQ). Biologics (TNF-i, etc.) → screen TB/Hep; ↑infection risk. Steroids → short bursts; taper; watch BP/glucose/weight. NSAIDs/salicylates → symptom relief; GI/renal watch. Team: Rheum leads; RN = med teaching & infection vigilance; PT/OT; psychosocial support. Key sx: Symmetric polyarthritis, prolonged stiffness, fatigue/low-grade fever, nodules; extra-articular: pleurisy, pericarditis, vasculitis. RN priorities: Balance rest/activity (8–10h sleep), splints, monitor ESR/CRP, strict infection precautions. RA Quick Hits: Early aggressive therapy; energy conservation; monitor for immunosuppression. 3) 💥 Gout Patho: Hyperuricemia → urate crystals (joints/tissues). Acute meds: Colchicine, NSAIDs (start fast). Chronic meds: Allopurinol/Febuxostat (↓production; febuxostat CV/hepatic alerts), Probenecid (↑excretion; fluids 2–3 L/day). Team: HCP confirms (crystals), starts ULT; RN pain/joint protection; RD diet. Key sx: Podagra (1st MTP) red, hot, exquisitely tender; tophi (chronic); renal stones risk. RN priorities: Bedrest affected joint; cradle for sheets; hydrate; monitor uric acid/renal labs; diet ↓purines; no alcohol (esp. beer/wine). Gout Quick Hits: Rapid pain control + fluids; lifestyle + adherence prevent flares. 4) 🦋 Systemic Lupus Erythematosus (SLE) Patho: Multisystem autoimmune (Type III ICs) → skin, joints, kidneys, heart, CNS. Meds: Steroids (organ threats), HCQ (rash/fatigue; eye exams), Immunosuppressants (AZA, CYC, MMF; labs/infection risk), NSAIDs (caution kidneys). Team: Rheum ± nephro/cardio; RN monitors organs & infection; sun safety; psychosocial; nutrition. Key sx/risks: Malar rash & photosensitivity, profound fatigue; lupus nephritis (proteinuria/HTN), serositis, neuropsych sx, infection risk. RN priorities: Daily weights/I&O/BP; strict med adherence; sun block/clothing; plan rest/activity; fever = evaluate for infection. SLE Quick Hits: Sun protection mandatory; watch kidneys & infections.

MEDSURG | DM & Endocrine Primer

🧪 DIABETES MELLITUS (DM) Patho: • T1DM: Autoimmune β-cell loss → absolute insulin ↓ → ketosis prone. • T2DM: Insulin resistance + relative insulin ↓; ketosis rare (stress/infection). • Prediabetes: IFG 100–125; IGT 140–199 (OGTT). Acute priorities: • Hypoglycemia (<70): Rule of 15 → 15 g fast CHO, recheck 15 min; repeat PRN. If NPO/LOC: IM glucagon or IV D50. • DKA (T1): Kussmaul, fruity breath, ketones. • HHS (T2): Glu >600, severe dehydration, neuro changes. → 1st: fluids (0.9% NS), then IV regular insulin; replace K⁺ as indicated; add D5 when BG ≈250 (DKA)/300 (HHS). 🔥 HYPERTHYROIDISM (Graves) Patho: TSH-receptor antibodies → ↑T3/T4; ↑metabolic/SNS activity. Meds: Methimazole/PTU (PTU for storm/1st trimester); β-blockers for symptoms; RAI (non-pregnant) with radiation precautions (response up to 3 mo). Diet: High-cal (4–5k/day); avoid caffeine/highly seasoned/high-fiber. Key signs: Heat intolerance, weight loss ↑ appetite, tremor, palpitations, exophthalmos. Thyroid storm: Tachyarrhythmias & hyperthermia → cool/calm room, β-blockers, antithyroid, fluids, treat triggers. Teach: Watch for hypothyroid after RAI/surgery. 🧊 HYPOTHYROIDISM Patho: ↓T3/T4 (primary ↑TSH); causes: Hashimoto, iodine lack, post-therapy. Meds: Levothyroxine—lifelong. Start low, go slow (cardiac risk). Signs: Cold intolerance, weight gain, dry coarse skin/hair, bradycardia, hyperlipidemia, constipation, fatigue; ↑ sensitivity to sedatives/opioids. Myxedema coma: Airway/vent, IV levothyroxine, warm, hemodynamic support. Diet: Low-cal until euthyroid. Teach: Daily AM empty-stomach dosing; don’t stop; report chest pain/palpitations. 🐯 CUSHING SYNDROME Patho: Excess glucocorticoids (often exogenous) ± mineralocorticoids → hyperglycemia, HTN, hypokalemia, protein catabolism, osteoporosis. Signs: Moon face, truncal obesity, thin skin/easy bruising, poor healing, weakness. Care: Treat cause (surgery if tumor); infection/VTE precautions; glucose/BP/weight/skin monitoring. Steroids: Never stop abruptly—taper to avoid adrenal crisis. Teach: Sick-day plans; infection signs may be masked. 🧂 ADDISON’S DISEASE (Primary adrenal insufficiency) Patho: ↓ cortisol and aldosterone → Na↓, K⁺↑, volume↓. Meds: Hydrocortisone (↑ dose with stress; split dosing) + fludrocortisone AM. Signs: Hyperpigmentation, weight loss, fatigue, salt craving, hypotension. Addisonian crisis: Triggered by stress/abrupt steroid stop → shock, severe N/V/D, Na↓, K⁺↑. Tx (crisis): High-dose IV hydrocortisone, rapid 0.9% NS + D5, monitor K⁺/glucose; ECG. Teach: Medical ID, stress-dose steroids, IM hydrocortisone kit use, ↑ dietary salt.

MEDSURG | DM & Endocrine

🧪 DIABETES MELLITUS (DM) Patho: • T1DM: Autoimmune β-cell loss → absolute insulin ↓ → ketosis prone. • T2DM: Insulin resistance + relative insulin ↓; ketosis rare (stress/infection). • Prediabetes: IFG 100–125; IGT 140–199 (OGTT). Acute priorities: • Hypoglycemia (<70): Rule of 15 → 15 g fast CHO, recheck 15 min; repeat PRN. If NPO/LOC: IM glucagon or IV D50. • DKA (T1): Kussmaul, fruity breath, ketones. • HHS (T2): Glu >600, severe dehydration, neuro changes. → 1st: fluids (0.9% NS), then IV regular insulin; replace K⁺ as indicated; add D5 when BG ≈250 (DKA)/300 (HHS). 🔥 HYPERTHYROIDISM (Graves) Patho: TSH-receptor antibodies → ↑T3/T4; ↑metabolic/SNS activity. Meds: Methimazole/PTU (PTU for storm/1st trimester); β-blockers for symptoms; RAI (non-pregnant) with radiation precautions (response up to 3 mo). Diet: High-cal (4–5k/day); avoid caffeine/highly seasoned/high-fiber. Key signs: Heat intolerance, weight loss ↑ appetite, tremor, palpitations, exophthalmos. Thyroid storm: Tachyarrhythmias & hyperthermia → cool/calm room, β-blockers, antithyroid, fluids, treat triggers. Teach: Watch for hypothyroid after RAI/surgery. 🧊 HYPOTHYROIDISM Patho: ↓T3/T4 (primary ↑TSH); causes: Hashimoto, iodine lack, post-therapy. Meds: Levothyroxine—lifelong. Start low, go slow (cardiac risk). Signs: Cold intolerance, weight gain, dry coarse skin/hair, bradycardia, hyperlipidemia, constipation, fatigue; ↑ sensitivity to sedatives/opioids. Myxedema coma: Airway/vent, IV levothyroxine, warm, hemodynamic support. Diet: Low-cal until euthyroid. Teach: Daily AM empty-stomach dosing; don’t stop; report chest pain/palpitations. 🐯 CUSHING SYNDROME Patho: Excess glucocorticoids (often exogenous) ± mineralocorticoids → hyperglycemia, HTN, hypokalemia, protein catabolism, osteoporosis. Signs: Moon face, truncal obesity, thin skin/easy bruising, poor healing, weakness. Care: Treat cause (surgery if tumor); infection/VTE precautions; glucose/BP/weight/skin monitoring. Steroids: Never stop abruptly—taper to avoid adrenal crisis. Teach: Sick-day plans; infection signs may be masked. 🧂 ADDISON’S DISEASE (Primary adrenal insufficiency) Patho: ↓ cortisol and aldosterone → Na↓, K⁺↑, volume↓. Meds: Hydrocortisone (↑ dose with stress; split dosing) + fludrocortisone AM. Signs: Hyperpigmentation, weight loss, fatigue, salt craving, hypotension. Addisonian crisis: Triggered by stress/abrupt steroid stop → shock, severe N/V/D, Na↓, K⁺↑. Tx (crisis): High-dose IV hydrocortisone, rapid 0.9% NS + D5, monitor K⁺/glucose; ECG. Teach: Medical ID, stress-dose steroids, IM hydrocortisone kit use, ↑ dietary salt.

MEDSURG | Liver & Biliary

🟠 Cirrhosis Patho: Hepatocyte loss → fibrotic nodules → portal HTN → varices/ascites; ↓ albumin & clotting factors; ↑ ammonia → hepatic encephalopathy (HE). Meds: • Diuretics: spironolactone (K⁺-sparing), furosemide (K⁺-wasting) → track I&O, K⁺. • Ammonia ↓: lactulose (2–3 soft stools/day), rifaximin (↓ gut bacteria). • Varices: non-selective β-blockers (propranolol/nadolol) prevent bleed; octreotide acutely; vasopressin rescue. • Coags: vit K if PT/INR prolonged. Watch for: Variceal bleed (hematemesis/melena → shock). HE grade 3–4 (confusion→coma). Coagulopathy (bruising, epistaxis). Ascites/edema (SBP risk). Jaundice, spider angiomas, palmar erythema. RN priorities: • HE: q2h neuro, asterixis, NH₃; give lactulose/rifaximin; remove GI blood; bowel regimen. • Ascites: daily weight, I&O, girth marks, skin checks; Na restriction; diuretics; semi-Fowler’s; void pre-paracentesis. • Varices: vitals, PT/INR, platelets; no ETOH/NSAIDs/aspirin; β-blocker adherence. Active bleed → 2 large-bore IVs, type & cross, octreotide; balloon tamponade safety (label/secure; scissors at bedside). Pearls: Prolonged PT/INR, low albumin signal decline; fetor hepaticus = HE. 🔴 Acute Pancreatitis Patho: Premature enzyme activation → autodigestion, necrosis/hemorrhage → massive third-spacing → hypovolemia/shock; fat necrosis → hypocalcemia. Meds: IV opioids (morphine/dilaudid), dicyclomine, PPIs/H2, antacids. Red flags: Shock (hypotension/tachy). Resp: effusions/atelectasis → ARDS. Severe LUQ/epigastric pain → to back, not relieved by emesis. Hemorrhage signs: Cullen (umbilicus), Grey-Turner (flanks). Hypocalcemia (Chvostek/Trousseau) 🟡 Viral Hepatitis (A–E) Patho: Viral hepatocyte injury → inflammation/necrosis; ↓ bilirubin processing → jaundice; chronic HBV/HCV → fibrosis → cirrhosis/HCC. Tx: • Acute: supportive only (rest, nutrition; antihistamines for pruritus). • Chronic HCV: DAAs (e.g., sofosbuvir/velpatasvir) → >95% cure. • Chronic HBV: tenofovir/entecavir long-term; peg-IFN (flu-like sx, depression). • Diet: well-balanced, small frequent meals; no alcohol. Phases/Signs: • Acute/icteric: jaundice, malaise, low-grade fever, RUQ pain, anorexia; early smell aversion/food repugnance. • Convalescent: prolonged fatigue (wks–mos). • Fulminant failure: encephalopathy + coagulopathy → ICU.

MEDSURG | Liver and Biliary Primer

🟠 Cirrhosis Patho: Hepatocyte loss → fibrotic nodules → portal HTN → varices/ascites; ↓ albumin & clotting factors; ↑ ammonia → hepatic encephalopathy (HE). Meds: • Diuretics: spironolactone (K⁺-sparing), furosemide (K⁺-wasting) → track I&O, K⁺. • Ammonia ↓: lactulose (2–3 soft stools/day), rifaximin (↓ gut bacteria). • Varices: non-selective β-blockers (propranolol/nadolol) prevent bleed; octreotide acutely; vasopressin rescue. • Coags: vit K if PT/INR prolonged. Watch for: Variceal bleed (hematemesis/melena → shock). HE grade 3–4 (confusion→coma). Coagulopathy (bruising, epistaxis). Ascites/edema (SBP risk). Jaundice, spider angiomas, palmar erythema. RN priorities: • HE: q2h neuro, asterixis, NH₃; give lactulose/rifaximin; remove GI blood; bowel regimen. • Ascites: daily weight, I&O, girth marks, skin checks; Na restriction; diuretics; semi-Fowler’s; void pre-paracentesis. • Varices: vitals, PT/INR, platelets; no ETOH/NSAIDs/aspirin; β-blocker adherence. Active bleed → 2 large-bore IVs, type & cross, octreotide; balloon tamponade safety (label/secure; scissors at bedside). Pearls: Prolonged PT/INR, low albumin signal decline; fetor hepaticus = HE. 🔴 Acute Pancreatitis Patho: Premature enzyme activation → autodigestion, necrosis/hemorrhage → massive third-spacing → hypovolemia/shock; fat necrosis → hypocalcemia. Meds: IV opioids (morphine/dilaudid), dicyclomine, PPIs/H2, antacids. Red flags: Shock (hypotension/tachy). Resp: effusions/atelectasis → ARDS. Severe LUQ/epigastric pain → to back, not relieved by emesis. Hemorrhage signs: Cullen (umbilicus), Grey-Turner (flanks). Hypocalcemia (Chvostek/Trousseau) 🟡 Viral Hepatitis (A–E) Patho: Viral hepatocyte injury → inflammation/necrosis; ↓ bilirubin processing → jaundice; chronic HBV/HCV → fibrosis → cirrhosis/HCC. Tx: • Acute: supportive only (rest, nutrition; antihistamines for pruritus). • Chronic HCV: DAAs (e.g., sofosbuvir/velpatasvir) → >95% cure. • Chronic HBV: tenofovir/entecavir long-term; peg-IFN (flu-like sx, depression). • Diet: well-balanced, small frequent meals; no alcohol. Phases/Signs: • Acute/icteric: jaundice, malaise, low-grade fever, RUQ pain, anorexia; early smell aversion/food repugnance. • Convalescent: prolonged fatigue (wks–mos). • Fulminant failure: encephalopathy + coagulopathy → ICU.

MEDSURG | Diabetes

🧪 DIABETES MELLITUS (DM) Patho: • T1DM: Autoimmune β-cell loss → absolute insulin ↓ → ketosis prone. • T2DM: Insulin resistance + relative insulin ↓; ketosis rare (stress/infection). • Prediabetes: IFG 100–125; IGT 140–199 (OGTT). Meds (need-to-know): • Insulin: Rapid lispro/aspart (≤15 min pre-meal); regular (30–45 min pre-meal); long-acting glargine/detemir/degludec (don’t mix). • Metformin: 1st-line T2DM; hold 24–48h pre & ≥48h post iodinated contrast. • SUs: glipi/glyburide/glime—hypoglycemia; take 30 min before meals. • SGLT2i: empa/dapa/cana—UTI/genital infections; hydrate after dose. Acute priorities: • Hypoglycemia (<70): Rule of 15 → 15 g fast CHO, recheck 15 min; repeat PRN. If NPO/LOC: IM glucagon or IV D50. • DKA (T1): Kussmaul, fruity breath, ketones. • HHS (T2): Glu >600, severe dehydration, neuro changes. → 1st: fluids (0.9% NS), then IV regular insulin; replace K⁺ as indicated; add D5 when BG ≈250 (DKA)/300 (HHS). Chronic care: A1C goal <7% (often 6.5–7); rotate sites (abdomen fastest); daily feet check; annual eye/foot; store insulin room temp ≤4 wks. Quick cues: • Contrast? Hold metformin. • DKA triad: BG>250, pH<7.30, HCO₃<16 + ketones. • Exercise (T1): Avoid vigorous if BG ≥250 and ketones.

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