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Topic 4

Part of the HAAD (UAE) study roadmap. Botany topic nursin-004 of Botany.

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Medical-Surgical Nursing

Medical-surgical nursing encompasses the care of adult patients with acute and chronic medical conditions and those recovering from surgery. It is the largest specialty in nursing and serves as the foundation for all other nursing specialties. In the UAE healthcare system, med-surg nurses work in diverse settings — from tertiary referral hospitals like Sheikh Khalifa Medical City to regional hospitals in Al Ain and specialized centers in Dubai. The HAAD examination tests med-surg nursing knowledge extensively because it encompasses the nursing care of the most common conditions affecting the UAE population: cardiovascular disease, diabetes, respiratory conditions, renal disease, and surgical patients. This chapter covers the key medical-surgical conditions and nursing management priorities for HAAD candidates.

Cardiovascular Disorders

Coronary Artery Disease (CAD) and Myocardial Infarction (MI)

Pathophysiology: Atherosclerotic plaque builds up in coronary arteries → luminal narrowing → reduced blood flow to myocardium. When demand exceeds supply (exercise, stress), ischemia occurs (angina). Complete occlusion → myocardial infarction (death of heart muscle).

Stable angina: Predictable chest pain/pressure on exertion; relieved by rest and nitroglycerin; < 15 minutes; no ECG changes or cardiac markers elevation.

Unstable angina: Chest pain at rest or with minimal exertion; new-onset; crescendo pattern; may have ECG changes (ST depression); elevated cardiac markers (troponin may be normal initially).

STEMI (ST-elevation MI): Complete coronary occlusion; ST elevation on ECG; troponin elevated (rises within 3–6 hours, peaks at 12–24 hours, remains elevated 7–14 days); Q waves develop later.

NSTEMI: Non-ST-elevation MI; troponin elevated; ST depression or T-wave inversion; may have partially occluded artery.

Nursing management of MI:

  • MONA: Morphine (pain relief, reduces preload), Oxygen (if SpO₂ < 94%), Nitroglycerin (vasodilation), Aspirin (antiplatelet) — MONA no longer recommended as a treatment acronym but individual components are valid
  • Acute pain management: IV morphine 2–4 mg PRN; assess pain (character, location, radiation, duration, response to nitroglycerin)
  • ECG monitoring: Continuous monitoring for arrhythmias (most dangerous complication in first 24–48 hours)
  • Reperfusion therapy: PCI (percutaneous coronary intervention) within 90 minutes of first medical contact (door-to-balloon time); thrombolytics (streptokinase, tPA) if PCI not available within 120 minutes
  • Bed rest: Semi-Fowler’s position; calm environment; 24–48 hours strict bed rest for STEMI
  • Cardiac rehabilitation: Phase I begins in hospital; phases II and III are outpatient

Heart Failure

Left-sided heart failure: Backup of blood in pulmonary circulation → pulmonary edema → dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), cough with frothy/pink sputum, crackles on auscultation, tachycardia.

Right-sided heart failure: Backup of blood in systemic circulation → peripheral edema (pedal, sacral), JVD (jugular venous distension), hepatomegaly, ascites, weight gain, fatigue.

Systolic vs. diastolic HF: Systolic (HFrEF) — reduced ejection fraction (<40%); dilated LV; most common cause is ischemic heart disease. Diastolic (HFpEF) — preserved EF but impaired LV filling; associated with hypertension, diabetes, aging.

Nursing management:

  • Position: High Fowler’s (45–60°) for dyspnea; peripheral edema management — elevate legs when sitting
  • Oxygen: 2–4 L/min via nasal cannula for hypoxemia
  • Fluid restriction: 1.5–2 L/day for severe HF
  • Daily weights: Same time, same scale, same clothing — 1 kg gain = 1 L fluid retention
  • Medications: ACE inhibitors/ARBs (reduce preload and afterload), beta-blockers (reduce mortality), diuretics (reduce preload), aldosterone antagonists (spironolactone — reduce mortality in moderate-severe HF), digoxin (increases contractility and controls rate in AF)
  • I&O monitoring: Strict input and output documentation

Hypertension

Definition: Sustained BP ≥ 130/80 mmHg (ACC/AHA 2017 guidelines). In UAE clinical practice, hypertension is typically defined as ≥ 140/90 mmHg.

Complications: Stroke, MI, heart failure, renal failure, retinopathy, peripheral vascular disease.

Nursing management:

  • Low-sodium diet (< 2 g/day)
  • Regular physical activity
  • Weight management
  • Medication adherence (antihypertensives — see Pharmacology chapter)
  • BP monitoring — home BP diary
  • Patient education on lifestyle modifications

Respiratory Disorders

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive, partially reversible airflow limitation caused by chronic inflammation (primarily from smoking). It includes chronic bronchitis (“blue bloater” — productive cough ≥ 3 months/year for ≥ 2 years) and emphysema (“pink puffer” — dyspnea, barrel chest, hyperinflation).

Signs and symptoms: Chronic productive cough, dyspnea on exertion and at rest in advanced disease, barrel chest, prolonged expiration with pursed-lip breathing, wheezing, reduced breath sounds (especially in emphysema), cyanosis (in chronic bronchitis).

Nursing management:

  • Smoking cessation: Most important intervention — slows disease progression
  • Oxygen therapy: Long-term oxygen therapy (LTOT) for chronic hypoxemia (PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88%) — 15+ hours/day
  • Medications: Bronchodilators (short-acting beta-agonists like salbutamol; long-acting agents like salmeterol); inhaled corticosteroids (for frequent exacerbations); mucolytics
  • Pulmonary rehabilitation: Exercise training, breathing techniques (pursed-lip breathing, diaphragmatic breathing), patient education
  • Airway clearance: Hydration, humidification, chest physiotherapy, flutter valve
  • Infection prevention: Pneumococcal and influenza vaccines; prompt treatment of exacerbations (often bacterial — antibiotics; purulent sputum)

Asthma

Pathophysiology: Chronic inflammatory airway disease with reversible airflow obstruction and bronchial hyperresponsiveness. Triggers include allergens, exercise, cold air, infections, stress.

Signs and symptoms: Episodic wheezing, dyspnea, chest tightness, coughing (especially at night/morning), prolonged expiration, use of accessory muscles in severe attacks.

Asthma classification (GINA): Intermittent, mild persistent, moderate persistent, severe persistent — based on symptom frequency, night symptoms, FEV1, and activity limitation.

Nursing management:

  • Acute exacerbation: Short-acting beta-agonist (SABA — salbutamol) via MDI with spacer; oxygen if hypoxemic; systemic corticosteroids (prednisone/prednisolone) for moderate-severe attacks
  • Long-term control: Inhaled corticosteroids (ICS) — first-line for persistent asthma; leukotriene receptor antagonists; long-acting beta-agonists (LABA — NEVER used alone without ICS)
  • Patient education: Inhaler technique (most patients use incorrectly — crucial to demonstrate); trigger avoidance; action plan (written); when to seek emergency care

Diabetes Mellitus

Type 1 vs. Type 2

Type 1 DM: Autoimmune destruction of pancreatic beta cells → absolute insulin deficiency; usually presents in childhood/adolescence; rapid onset; requires insulin from diagnosis; ketoacidosis-prone.

Type 2 DM: Insulin resistance + relative insulin deficiency; usually presents in adults (increasingly in children); associated with obesity; may be controlled with lifestyle, oral agents, or insulin; hyperosmolar hyperglycemic state (HHS) rather than DKA.

Diabetic Ketoacidosis (DKA)

Occurs in Type 1 DM (but also in Type 2 under stress). Precipitated by infection, missed insulin, MI, trauma.

Signs/symptoms: Hyperglycemia (often > 250 mg/dL), acidosis (pH < 7.3, bicarbonate < 18 mEq/L), ketonemia/ketonuria, Kussmaul breathing (deep, rapid respirations — trying to blow off CO₂ to compensate for metabolic acidosis), fruity breath (acetone from ketones), dehydration (dry mucous membranes, tachycardia, hypotension), altered consciousness.

Nursing management:

  • IV fluids: First priority — aggressive fluid resuscitation (0.9% NS initially); switch to D5 0.45% saline when blood glucose falls to 200–250 mg/dL
  • Insulin: IV regular insulin infusion (0.1 units/kg/hour); continue dextrose-containing fluids to prevent hypoglycemia while insulin continues
  • Potassium replacement: Total body potassium is depleted despite normal/high serum K⁺ (acidosis causes K⁺ to shift out of cells); replace as soon as K⁺ falls below 5.2 mEq/L and urine output established
  • Monitor: Blood glucose q1h, electrolytes (especially K⁺), pH, mental status, I&O

Renal Disorders

Acute Kidney Injury (AKI)

Sudden deterioration of renal function over hours to days. Causes:

  • Pre-renal (70%): Hypoperfusion (dehydration, hemorrhage, sepsis, cardiac failure)
  • Intrinsic (renal): Acute tubular necrosis (ATN — most common, from prolonged pre-renal hypoperfusion or nephrotoxins), acute interstitial nephritis (drug-induced — NSAIDs, antibiotics), acute glomerulonephritis
  • Post-renal: Obstruction of urinary outflow (stones, BPH, tumors)

Stages (KDIGO):

  • Stage 1: Cr 1.5–1.9× baseline or ≥ 0.3 mg/dL increase
  • Stage 2: Cr 2–2.9× baseline
  • Stage 3: Cr ≥ 3× baseline or Cr ≥ 4 mg/dL or renal replacement therapy

Nursing management:

  • Monitor I&O hourly; daily weights
  • Fluid restriction if oliguric
  • Electrolyte monitoring (hyperkalemia is the most life-threatening complication — can cause fatal arrhythmias)
  • Dietary: Low potassium, low sodium, protein restriction (if advanced)
  • Prepare for dialysis if indicated

Chronic Kidney Disease (CKD)

Progressive, irreversible loss of renal function over months to years. Most common causes in the UAE: diabetes mellitus and hypertension.

Stages 1–5 based on GFR (Glomerular Filtration Rate):

  • Stage 1: GFR ≥ 90 (with kidney damage)
  • Stage 5: GFR < 15 (kidney failure — dialysis or transplant required)

Complications: Anemia (reduced erythropoietin), hyperkalemia, metabolic acidosis, hyperphosphatemia and renal osteodystrophy (reduced vitamin D activation → calcium malabsorption → secondary hyperparathyroidism), fluid overload, uremia (accumulation of waste products → nausea, vomiting, pruritus, encephalopathy, pericarditis).

Renal replacement therapy: Hemodialysis (most common), peritoneal dialysis, kidney transplantation.

⚡ Exam tip: MONA is no longer recommended as a protocol for MI — but aspirin and nitroglycerin are still part of acute MI management. DKA requires insulin + fluids + potassium replacement (don’t withhold insulin for low potassium until K⁺ < 5.2). COPD patients with chronic hypoxemia need oxygen 15+ hours/day. AKI: pre-renal is most common and most reversible — treat hypoperfusion aggressively before it becomes intrinsic ATN.

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