NUR198 Master Study Guide

Normal aging — by system

• Cardio: stiffer vessels → ↑systolic BP, slower HR response to stress, orthostatic hypotension (fall risk — rise slowly)
• Resp: ↓lung elasticity, weaker cough, ↓cilia → pneumonia & aspiration risk
• Renal: ↓GFR (drugs clear slower!), nocturia, ↓thirst sensation → dehydration risk
• GI: ↓motility (constipation), ↓saliva, ↓intrinsic factor → B12 deficiency
• Neuro: slower processing is normal — confusion is NEVER normal aging (work it up: infection? meds? hypoxia?)
• Skin/MSK: thin fragile skin, ↓subcut fat, ↓bone density, ↓muscle mass → falls, fractures, pressure injuries, hypothermia
• Senses: presbyopia, presbycusis (hear low tones better — speak low and slow, face the client), ↓taste/smell

Nursing management

• Fall prevention bundle: assess risk, clutter-free, adequate lighting, nonslip footwear, call light in reach
• Skin: reposition q2h, minimal tape, moisturize; med doses often lower ("start low, go slow")

Nursing care (both)

• Reorient calmly, consistent caregivers, clocks/calendars, glasses/hearing aids ON, day-night routine, family at bedside
• Avoid restraints and unnecessary sedatives (worsen both); safety = wandering precautions for dementia

Polypharmacy

• Multiple meds + multiple prescribers + ↓renal/hepatic clearance = adverse events; anticholinergics, sedatives, opioids = Beers-list caution (falls, confusion)
• Nursing: full med reconciliation every visit — include OTC + herbals; watch for a "prescribing cascade" (new drug to treat another drug's side effect)

Elder abuse

• Types: physical, emotional, sexual, financial, neglect (most common); abuser is usually a known caregiver
• Red flags: injuries inconsistent with story, delays seeking care, poor hygiene/dehydration, caregiver answers all questions, fear of caregiver
• Nurses are mandatory reporters — interview the client alone; report suspicion (you don't have to prove it)

Ageism

• Stereotyping by age → undertreated pain, dismissed symptoms. Assess the person, not the birth year.

• Chronic = lasts ≥3 months (usually lifelong), fluctuates through remissions/exacerbations; goal = manage, not cure — maximize function and quality of life
• Trajectory phases: onset → stable → unstable → acute flare → comeback → downward → dying; nursing focus shifts by phase
• Self-management support = the core: teach-back method, simplify regimens, address cost/access barriers, involve family/caregivers
• Watch caregiver strain; connect to community resources; depression and social isolation are common — screen for both

• Hyponatremia <135: neuro (confusion, seizures, headache) from cell swelling. Causes: SIADH, excess water, diuretics. Tx: fluid restriction; hypertonic (3%) saline only for severe — correct SLOWLY (rapid = osmotic demyelination)
• Hypernatremia >145: thirst, dry mucosa, restless→lethargy, seizures. Causes: dehydration, ↓water intake, DI. Tx: hypotonic fluids/water, correct slowly (rapid = cerebral edema)

• Hypocalcemia: ↑neuromuscular excitability — +Trousseau (BP cuff→hand spasm), +Chvostek (cheek tap→twitch), tetany, laryngospasm, seizures. Causes: thyroid/parathyroid surgery, renal failure. Tx: IV calcium gluconate
• Hypercalcemia: "moans, groans, stones, bones" — weakness, ↓reflexes, kidney stones, constipation. Causes: hyperparathyroid, cancer, immobility. Tx: hydrate, ambulate, bisphosphonates
• Calcium and phosphorus are inverse; calcium and magnesium act the same direction clinically
• Hypomagnesemia: like hypocalcemia (tremor, +Chvostek/Trousseau, torsades). Hypermagnesemia: ↓reflexes, ↓BP, resp depression (classic in preeclampsia Mg therapy → antidote calcium gluconate)

Normals

• pH 7.35–7.45 · PaCO₂ 35–45 (respiratory) · HCO₃ 22–26 (metabolic)

ROME shortcut

• Respiratory Opposite: pH & CO₂ move opposite ways
• Metabolic Equal: pH & HCO₃ move the same way

Pre-op

• Informed consent: provider explains risks/benefits; nurse witnesses the signature & confirms understanding. Must be signed BEFORE sedation.
• NPO (usually after midnight/8 hr), hold/adjust meds (anticoagulants, insulin, some herbals), baseline vitals/labs, remove jewelry/dentures, teach coughing/IS/leg exercises, mark site, verify allergies

Intra-op

• Time-out (right patient/site/procedure), sterile field, positioning injury & skin protection, counts (sponges/instruments)

Post-op priorities (PACU → floor)

• Airway → breathing → circulation first. Then LOC, pain, surgical site/drains, N/V
• Prevent complications: IS + early ambulation (atelectasis/pneumonia, VTE), splint incision, monitor for hemorrhage (↑HR early), infection, paralytic ileus (bowel sounds/flatus)
• Dehiscence/evisceration: cover with sterile saline-soaked gauze, low-Fowler with knees bent, NPO, stay calm, call surgeon

• Qualify: BMI ≥40, or ≥35 with comorbidities, after failed conservative attempts
• Post-op: small sips → tiny frequent meals, protein first, no gulping, no straws/carbonation; risk of anastomotic leak (tachycardia, fever, ↑ pain → report), VTE, dumping syndrome
• Lifelong vitamin/mineral supplementation (B12, iron, Ca, D); airway/OSA precautions; bariatric-appropriate equipment + dignity

• Pain is what the client says it is — self-report is the gold standard. Use FLACC (nonverbal/kids), Wong-Baker faces, 0–10 numeric; PAINAD for dementia
• WHO ladder: non-opioids (acetaminophen — watch 4 g/day max, NSAIDs — GI/renal/bleeding) → weak → strong opioids; multimodal is best
• Opioids: monitor sedation + RR FIRST (respiratory depression is the danger); naloxone reverses; prevent constipation proactively (stimulant laxative, not just fiber)
• Non-pharm: heat/cold, positioning, distraction, massage, relaxation, TENS — adjuncts, not replacements

• Atopic dermatitis (eczema): dry itchy inflamed skin; moisturize, avoid triggers, topical steroids, don't scratch
• Herpes zoster (shingles): reactivated varicella along a dermatome (unilateral, doesn't cross midline), painful vesicles. Airborne + contact precautions if disseminated/immunocompromised; antivirals within 72 hr; risk of postherpetic neuralgia. Contagious to non-immune until crusted.
• Psoriasis: silvery scaly plaques (autoimmune, ↑ cell turnover); topical steroids, vitamin D analogs, phototherapy, biologics; not contagious
• Skin cancers — ABCDE for melanoma: Asymmetry, Border irregular, Color varied, Diameter >6 mm, Evolving. AK = precancerous; BCC = most common, rarely metastasizes; SCC can metastasize; melanoma = deadliest. Teach sun protection + monthly skin checks
• Skin grafts/flaps: monitor color/temp/cap refill of graft, immobilize, prevent pressure/shear on site

• Rhinitis/sinusitis/pharyngitis: mostly viral (supportive care); teach hand hygiene, hydration; antibiotics only if bacterial (strep throat)
• OSA: repeated apnea in sleep → daytime somnolence, loud snoring, morning headache, HTN. Tx = CPAP (adherence teaching is key), weight loss, avoid alcohol/sedatives, side-sleeping
• Epistaxis: sit up + lean FORWARD, pinch soft nose 10–15 min, ice; don't tilt head back (aspiration/swallowed blood)
• Laryngeal cancer: hoarseness >2 wk = red flag; smoking/alcohol; may need laryngectomy → permanent stoma, communication plan

• Pneumonia: fever, productive cough, crackles, ↑WBC, dyspnea, ↓SpO₂. Tx: antibiotics (bacterial), O₂, hydration, IS, position good lung down for oxygenation... affected lung up; prevention = IS, ambulation, vaccines
• Atelectasis: collapsed alveoli (common post-op) → ↓breath sounds; prevent/treat with IS, deep breathing, ambulation, coughing
• TB: airborne precautions, negative-pressure room, N95; positive s/s = night sweats, weight loss, hemoptysis, chronic cough; dx = sputum AFB × 3 (confirms), Mantoux/IGRA screens; RIPE meds for 6–9 months — teach adherence (rifampin turns secretions orange), report vision changes (ethambutol), no alcohol (isoniazid hepatotoxicity)

Pathophysiology

• Autosomal recessive, CFTR gene on chromosome 7. Most common mutation is F508del. Two carrier parents = 25% chance each pregnancy.
• Chloride is stuck inside the cell → water is not pulled into the secretion → mucus is thick.
• Sweat glands work backwards: chloride cannot be reabsorbed out of sweat, so the sweat comes out salty. That is the whole basis of the sweat test.
• Lungs: thick mucus plugs airways → trapped bacteria → chronic infection → inflammation → bronchiectasis → respiratory failure. This is what they die of.
• Pancreas: ducts plug → enzymes never reach the duodenum → fat and protein are not absorbed. Over time the gland fibroses and fills with fat, wrecking the islets → insulin insufficiency → CF-related diabetes (CFRD). It is not type 1 (not autoimmune) and not type 2. Screen annually with a 2-hour OGTT starting at age 10 — A1C is not used to screen. Treat with insulin, not oral agents, and do not put them on a diabetic or low-calorie diet — the CF high-calorie, high-fat diet still wins.

What you would see

• Salty-tasting skin — the parent says the baby tastes salty when kissed. Classic.
• Chronic productive cough, thick purulent sputum, recurrent pneumonia, wheezes and crackles.
• Steatorrhea — bulky, greasy, foul-smelling, floating stools.
• Failure to thrive despite a big appetite. They eat and eat and stay small.
• Meconium ileus in the newborn — occurs in about 15–20% and is nearly diagnostic of CF, but most babies are now found by newborn screening rather than by symptoms. Later, distal intestinal obstruction syndrome (DIOS) and rectal prolapse.
• Barrel chest, clubbing, nasal polyps, chronic sinusitis.
• 97–98% of men are infertile — congenital bilateral absence of the vas deferens. Infertile is not sterile: sperm production is normal in about 90%, so they can father children with surgical sperm retrieval and IVF. Women have reduced fertility from thick cervical mucus but can conceive — they still need contraception counselling.

Diagnostics

Medical management

• Dornase alfa breaks down the DNA released by dead white cells, which is what makes CF mucus so thick. Hypertonic saline 7% pulls water into the airway.
• Inhaled tobramycin (300 mg BID, 28 days on / 28 days off) or aztreonam for chronic Pseudomonas. Monitor for ototoxicity (tinnitus, hearing loss), nephrotoxicity and bronchospasm.
• CFTR modulators — ivacaftor, tezacaftor/ivacaftor, elexacaftor/tezacaftor/ivacaftor (Trikafta). These fix the protein itself rather than the symptoms, and they are chosen by mutation. Boxed warning: drug-induced liver injury. LFTs at baseline, monthly for 6 months, then every 3 months for a year, then annually — hold and report jaundice, right upper quadrant pain, nausea and vomiting. Also eye exams in children (cataracts), watch for new depression or suicidal ideation, give with fat-containing food, and avoid grapefruit.
• Pancreatic enzymes (pancrelipase) and fat-soluble vitamins A, D, E and K.
• No cough suppressants. The productive cough is how they clear the mucus — suppressing it is a classic wrong answer.
• Lung transplant for end-stage disease.

Nursing management

• Airway clearance before meals, or at least 1 hour after — doing it on a full stomach makes them vomit.
• Enzyme capsules may be opened onto a small amount of acidic soft food. The label rule is pH 4.5 or less — applesauce, bananas, pears. Do not crush or chew the beads; the coating protects the enzyme from stomach acid, and chewed beads irritate the mouth. Do not mix into milk, formula or breast milk — the pH is too high and it strips the coating. Give it immediately, then follow with fluid so none is left in the mouth.
• High-calorie, high-protein, high-fat diet — roughly 110–200% of normal calories. Do not put them on a low-fat diet; fat is fine once enzymes are on board.
• Extra salt, never restricted — they lose it in sweat. More in heat, fever and exercise.
• Watch for hemoptysis and pneumothorax — both are real risks in advanced disease.
• DIOS is not plain constipation. Right lower quadrant mass with obstruction → osmotic laxatives, polyethylene glycol or Gastrografin. Surgery is not the first move.
• ABPA (allergic bronchopulmonary aspergillosis): new wheezing, a drop in FEV₁ and a rising IgE that does not respond to antibiotics. Treated with corticosteroids plus an antifungal.
• Also chronic: osteopenia and osteoporosis (vitamin D malabsorption plus steroids) and CF liver disease (focal biliary cirrhosis, portal hypertension).
• Influenza, pneumococcal, COVID-19 and RSV immunization per schedule. Live vaccines are fine — CF itself does not make them immunosuppressed — unless they have had a transplant.
• Exercise is treatment, not just recreation — it helps clear secretions.

Teaching the family

• It is lifelong and progressive, but the numbers have changed enormously. Per the CF Foundation Patient Registry, a child born today has a median predicted survival in the mid-60s, and most people with CF in the US are now adults. Adherence genuinely moves that number.
• Airway clearance every day, even when they feel well. It is not a rescue treatment.
• Report a change in sputum colour, volume or thickness, new fever, weight loss, or a drop in exercise tolerance — those are the early signs of an exacerbation.
• Genetic counselling for the parents and for the client of childbearing age.
• Salty skin is expected; extra salt in hot weather is a safety issue, not a preference.

• COPD: chronic bronchitis + emphysema; barrel chest, prolonged expiration, ↑CO₂ retention. Low-flow O₂ titrated to SpO₂ 88–92%; pursed-lip & diaphragmatic breathing, tripod position, small frequent high-cal meals, smoking cessation #1, vaccines
• Asthma: reversible bronchospasm; wheeze, chest tightness, cough. SABA (albuterol) = rescue FIRST, then inhaled corticosteroid = controller (rinse mouth after — thrush). Silent chest / no wheezing in severe attack = ominous (no air moving). Peak flow monitoring: green/yellow/red zones
• Lung cancer: chronic cough, hemoptysis, weight loss; smoking = #1 risk; often late dx; management by stage (surgery/chemo/radiation) + symptom control
• Pulmonary embolism: sudden dyspnea, pleuritic chest pain, tachycardia, ↓SpO₂, anxiety. Full PE card is just above ↑

• Stable angina: predictable, with exertion, relieved by rest + nitro. Unstable angina/MI: at rest, NOT relieved → emergency
• MI signs: crushing substernal pain radiating to jaw/left arm, diaphoresis, N/V, dyspnea, doom; women/elderly/diabetics = atypical (fatigue, indigestion, SOB)
• Immediate care (MONA-ish, not strict order): O₂ if <90%, aspirin (chew), nitroglycerin (hold if SBP<90 or PDE-5 inhibitor use), morphine; get 12-lead + troponin (most specific marker, rises 3–4 hr)
• Nitro teaching: 1 tab q5min ×3, call 911 if no relief after first dose; burning/headache expected; sit down (hypotension)
• Reperfusion: PCI (goal door-to-balloon <90 min) or thrombolytics; post-cath watch site bleeding, keep leg straight, pulses distal

• ECG basics: P wave = atrial depolarization, QRS = ventricular depolarization, T = repolarization; regularity + rate + P:QRS
• A-fib: irregularly irregular, no clear P waves → clot/stroke risk → anticoagulation; rate control (beta-blocker/CCB/digoxin)
• V-tach WITH pulse: antiarrhythmics ± synchronized cardioversion. V-tach without pulse / V-fib: DEFIBRILLATE (unsynchronized) + CPR
• Asystole/PEA: NOT shockable → CPR + epinephrine
• Bradycardia (symptomatic): atropine → pacing. Pacemaker/AICD teaching: check pulse, avoid strong magnets/MRI, no arm raised above shoulder initially, report dizziness

• "Silent killer"; ≥130/80 (stage 1). Damages heart, brain, kidneys, eyes. Lifestyle first: DASH diet, ↓Na⁺, weight loss, exercise, limit alcohol, no smoking
• Drug classes (see your antihypertensive chart): ACE inhibitors (-pril: dry cough, hyperkalemia, angioedema), ARBs (-sartan), beta-blockers (-olol: check HR/BP first, mask hypoglycemia), CCBs (-dipine), diuretics (give AM, monitor K⁺)
• Teaching: take even when feeling fine, don't stop abruptly (rebound), rise slowly (orthostatic), home BP log

• Management: daily weight (report 2–3 lb/day or 5 lb/week gain), Na⁺/fluid restriction, diuretics, ACE/ARB, beta-blocker, high Fowler + O₂ for dyspnea
• Digoxin: ↑contractility, ↓HR. Hold if apical HR <60; toxicity = N/V, anorexia, visual halos/yellow-green, confusion; hypokalemia ↑ toxicity risk; therapeutic 0.5–2

• Valve disorders (stenosis/regurgitation): murmurs, fatigue, HF symptoms; may need valve replacement (mechanical = lifelong anticoagulation)
• Pericarditis: sharp pleuritic chest pain relieved by sitting/leaning forward, friction rub; watch for cardiac tamponade (Beck triad: ↓BP, muffled heart sounds, JVD → emergency pericardiocentesis)
• Endocarditis: fever, new murmur, Janeway lesions/Osler nodes, splinter hemorrhages; needs long-term IV antibiotics, prophylaxis before dental work
• Myocarditis/cardiomyopathy: impaired pump → HF/arrhythmia; supportive, may progress to transplant

• DVT: unilateral warmth, redness, swelling, pain; don't massage (embolus risk); anticoagulation, elevate, SCDs prevent. Watch for PE.
• AAA: often silent; pulsatile abdominal mass, do NOT palpate deeply; rupture = sudden severe back/abd pain + hypotension = emergency
• Raynaud: vasospasm → white→blue→red fingers with cold/stress; keep warm, avoid triggers/nicotine, CCBs

• Cystitis: dysuria, frequency, urgency, cloudy/foul urine, suprapubic pain. Pyelonephritis: add flank pain (CVA tenderness), high fever, chills, N/V — more serious
• Elderly: confusion may be the ONLY sign of a UTI
• Teach: wipe front→back, void after intercourse, hydrate, cotton underwear, finish antibiotics; cranberry may help prevent
• CAUTI prevention: only use catheter when necessary, remove ASAP, sterile insertion, keep bag below bladder, closed system, secure tubing, peri care

• Sudden ↓ kidney function. Causes: Pre-renal (↓perfusion — hypovolemia, HF), Intra-renal (ATN, nephrotoxins/contrast), Post-renal (obstruction — stones, BPH)
• Oliguric phase = most dangerous: fluid overload, hyperkalemia (peaked T waves → arrest), metabolic acidosis, ↑BUN/creatinine → then diuretic phase (watch dehydration/hypokalemia)
• Nursing: strict I&O + daily weight, monitor K⁺/electrolytes, restrict fluid/K⁺/Na⁺, avoid nephrotoxins, prep for dialysis if severe

• Progressive irreversible ↓GFR; causes = diabetes + HTN (top two). Uremia → everything backs up
• S/S: fluid overload, hyperkalemia, metabolic acidosis, ↑phosphate / ↓calcium → bone disease, anemia (↓EPO), uremic frost/pruritus, nausea
• Diet: restrict protein, sodium, potassium, phosphorus, fluid; phosphate binders WITH meals; EPO + iron for anemia; active vitamin D; no Mg antacids

• Renal calculi: severe flank pain radiating to groin, hematuria; strain all urine, hydrate, pain control, ambulate; diet depends on stone type (limit oxalate/purine/Na⁺)
• Glomerulonephritis: often post-strep; hematuria (tea-colored), proteinuria, edema, HTN; supportive + treat cause
• Nephrotic syndrome: massive proteinuria, hypoalbuminemia, edema, hyperlipidemia; low-Na⁺, monitor for infection/clots
• PKD: genetic; fluid-filled cysts → enlarged kidneys, flank pain, HTN, hematuria → eventual CKD
• Bladder cancer: painless hematuria = classic; smoking risk; urinary diversion → ostomy/stoma care, mucus in urine normal with ileal conduit
• Transplant: lifelong immunosuppression; watch rejection (fever, ↓UOP, ↑creatinine, tenderness over graft, HTN) and infection

• Irreversible liver scarring (alcohol, hepatitis, NAFLD). Loss of function → ↓clotting factors (bleeding), ↓albumin (edema/ascites), ↑bilirubin (jaundice), ↑ammonia (encephalopathy)
• Portal HTN → ascites (daily weight + abdominal girth, low Na⁺, paracentesis — void first, monitor for hypovolemia after) and esophageal varices
• Esophageal varices = emergency: massive hematemesis → airway + volume, octreotide, endoscopic banding, balloon tamponade; avoid straining/coughing/NSAIDs
• Bleeding risk everywhere: soft toothbrush, electric razor, monitor coags, watch for occult bleeding

• Failing liver can't clear ammonia → neuro decline: confusion, personality change, asterixis (flapping tremor), ↑ammonia, → coma
• Lactulose = key treatment: traps & excretes ammonia in stool — titrate to 2–3 soft stools/day (too many = dehydration); rifaximin adjunct
• Protein historically restricted in acute severe cases — modern practice keeps adequate protein; follow orders; assess LOC frequently, safety

• Hep A & E: fecal-oral (contaminated food/water) — acute, usually self-limited; hand hygiene, sanitation
• Hep B, C, D: blood/body fluids (sex, needles, perinatal) — can become chronic → cirrhosis/cancer. Hep B vaccine exists; Hep C = leading cause of transplant, now curable with antivirals
• S/S: jaundice, dark urine, clay stools, fatigue, RUQ pain, ↑LFTs; standard precautions, avoid hepatotoxins (alcohol, acetaminophen)
• Liver cancer: often on top of cirrhosis/hep; ↑AFP; poor prognosis; palliative + targeted therapies

• Autodigestion of the pancreas. Causes: gallstones + alcohol (top two). Severe epigastric/LUQ pain radiating to back, worse lying flat/eating; N/V
• Labs: ↑amylase & lipase (lipase more specific); Cullen sign (periumbilical bruising) / Grey Turner (flank bruising) = hemorrhagic (serious)
• Management: NPO (rest the pancreas), IV fluids, pain control, NG suction if vomiting; monitor hypocalcemia (+Chvostek/Trousseau) and hyperglycemia; low-fat diet when resuming; no alcohol

• Caries: prevention = brushing/flossing, fluoride, limit sugars, regular dental care. Untreated → abscess, systemic infection.
• Parotitis (inflamed parotid gland): classic in elderly, dehydrated, NPO, or post-op clients with poor oral hygiene — staph. Prevent with oral care + hydration. S/S: painful swelling ear/jaw area, fever.
• Sialolithiasis (salivary stone): pain/swelling that worsens with eating. Tx: hydration, warm compresses, sour candy/sialagogues to stimulate flow, massage, possible removal.

Risk factors

• Tobacco (all forms) + alcohol (synergistic), HPV-16, sun exposure (lip), poor oral hygiene, male >50

Manifestations

• Painless ulcer/sore that doesn't heal in 2+ weeks (most common early sign)
• Leukoplakia (white patch, precancerous) and erythroplakia (red velvety patch — higher malignancy risk)
• Later: dysphagia, ear pain, voice change, neck lump

Management

• Biopsy = definitive dx. Surgery, radiation, chemo. Early detection = high cure rate → teach monthly self-exam of mouth for smokers/drinkers.

Two types — know the difference

Management & teaching

• Small frequent meals; stay upright 1–2 hr after eating; don't eat 2–3 hr before bed
• Elevate HOB on 4–6 inch blocks; weight loss; avoid tight clothing, heavy lifting, straining
• Antacids/PPIs for reflux; surgery = Nissen fundoplication (fundus wrapped around LES). Post-Nissen: small meals, avoid carbonation/gas-producing foods, report dysphagia

Patho / causes

• Incompetent LES lets gastric acid reflux into esophagus. Risks: obesity, pregnancy, smoking, hiatal hernia, caffeine, alcohol, fatty/fried foods, chocolate, peppermint, carbonation, NSAIDs

Manifestations

• Pyrosis (heartburn), regurgitation, dyspepsia; worse after meals and lying down
• Atypical: chronic cough, laryngitis/hoarseness, asthma-like symptoms, sore throat, non-cardiac chest pain (rule out MI first!)

Diagnostics

• Often clinical + trial of PPI. EGD if alarm signs (dysphagia, weight loss, bleeding, anemia). Ambulatory 24-hr pH monitoring = most accurate. Barium swallow shows hernia/strictures.

Management (step-up)

• Lifestyle first: weight loss, elevate HOB (blocks — not pillows), no food 2–3 hr before bed, small low-fat meals, avoid trigger foods, stop smoking/alcohol, stay upright after meals, avoid tight clothes
• Antacids (PRN symptom relief), H2 blockers (famotidine), PPIs = most effective (omeprazole, pantoprazole) — take 30–60 min BEFORE breakfast
• PPI long-term risks: fractures/osteoporosis, C. diff, pneumonia, B12 deficiency, hypomagnesemia

Complications

• Esophagitis → strictures (progressive dysphagia) → Barrett esophagus → adenocarcinoma

• Chronic acid exposure → normal squamous epithelium is replaced by columnar (intestinal) cells = metaplasia
• Precancerous — increases risk of esophageal adenocarcinoma
• Dx/monitoring: EGD with biopsy; surveillance endoscopy at set intervals
• Tx: aggressive long-term PPI therapy, GERD lifestyle measures; dysplasia → radiofrequency ablation or endoscopic resection
• Teaching: this is why "just heartburn" needs follow-up — adherence to surveillance is the key point

Risks / patho

• Adenocarcinoma (lower ⅓): GERD, Barrett, obesity. Squamous cell (upper ⅔): smoking, alcohol.

Manifestations — usually LATE (poor prognosis)

• Progressive dysphagia: solids first, then liquids — the classic clue
• Weight loss, odynophagia, regurgitation, hoarseness, chronic cough

Management

• EGD + biopsy = definitive. Staging CT/EUS/PET.
• Esophagectomy ± chemo/radiation; stents/dilation for palliation; nutrition support (often enteral) before surgery

Post-esophagectomy priorities

• Airway/pulmonary hygiene #1 (thoracic incision, aspiration risk); semi-Fowler+
• NEVER reposition, irrigate, or reinsert the NG tube — it protects the anastomosis; call the surgeon
• Watch for anastomotic leak: fever, tachycardia, chest pain, subcutaneous emphysema → report immediately

Causes

• H. pylori = #1 cause; NSAIDs/aspirin = #2 (block protective prostaglandins); also smoking, alcohol, stress, corticosteroids, Zollinger-Ellison

Gastric vs duodenal — classic exam table

Diagnostics

• EGD with biopsy = gold standard; H. pylori testing: urea breath test (hold PPIs ~2 wk and antibiotics before), stool antigen, biopsy

Management

• H. pylori: triple therapy = PPI + clarithromycin + amoxicillin (metronidazole if PCN allergy), 10–14 days — finish ALL of it
• Stop NSAIDs, smoking, alcohol, caffeine; sucralfate coats ulcer (give on empty stomach, 1 hr before meals, not with other meds); misoprostol protects if NSAIDs unavoidable (never in pregnancy)

Complications — know all three

• Hemorrhage (most common): hematemesis, coffee-ground emesis, melena, ↓BP ↑HR → NPO, 2 large-bore IVs, fluids/blood, endoscopic hemostasis
• Perforation (most lethal): sudden, severe upper abd pain → rigid board-like abdomen, shoulder pain (referred), fever, absent bowel sounds = peritonitis → NPO, NG suction, IV fluids + antibiotics, emergency surgery. Do NOT give anything PO.
• Obstruction (pyloric): fullness, vomiting undigested food, distension

• Acute: NSAIDs, alcohol, stress (burns, sepsis, ICU = stress ulcer prophylaxis), contaminated food. S/S: epigastric pain, N/V, anorexia, possible bleeding.
• Chronic: H. pylori (most common) or autoimmune (attacks parietal cells → no intrinsic factor → pernicious anemia)
• Tx: remove the cause; NPO during acute phase then clear liquids → bland diet; PPIs/H2 blockers; treat H. pylori; B12 for autoimmune type
• Teaching: avoid alcohol, NSAIDs, caffeine, spicy foods; small frequent meals; report black/tarry stools

• Risks: H. pylori, chronic gastritis, pernicious anemia, smoked/salted/pickled foods, smoking, family history, prior gastric surgery
• Early = vague → usually diagnosed LATE: early satiety, anorexia, weight loss, vague epigastric discomfort, fatigue (anemia)
• Late: palpable mass, ascites, obstruction signs
• Dx: EGD + biopsy; CT for staging; CEA/CA 19-9 markers may be monitored
• Tx: gastrectomy (partial/total) ± chemo/radiation → leads to gastrectomy complications below (dumping, B12 deficiency)

Post-op priorities

• NG tube to decompress: do NOT irrigate or reposition without a surgeon's order (protects the suture line); scant bloody drainage early = expected, frank red bleeding or large volumes = report
• Semi-Fowler; pulmonary hygiene (incentive spirometer, splint incision); early ambulation; monitor for anastomotic leak (fever, tachycardia, abd pain)

Long-term complications — the exam favorites

• Dumping syndrome (see its own card)
• Pernicious anemia: parietal cells gone → no intrinsic factor → lifelong B12 injections
• Iron-deficiency anemia, calcium/vitamin D malabsorption → osteoporosis, weight loss

• Patho: autoimmune destruction of parietal cells (or gastrectomy) → no intrinsic factor → B12 can't be absorbed in the ileum
• S/S: fatigue, pallor, beefy red smooth sore tongue (glossitis), and the differentiator — neuro signs: paresthesias (numbness/tingling), ataxia, ↓proprioception, confusion
• Dx: ↓serum B12, macrocytic RBCs (↑MCV), intrinsic factor antibodies
• Tx: lifelong parenteral (IM) B12 — weekly then monthly — or high-dose intranasal; oral won't work without intrinsic factor
• Teaching: it's lifelong; missed doses → irreversible neuro damage; safety with ataxia (falls)

Patho

• After gastrectomy/bypass, hypertonic chyme "dumps" rapidly into the jejunum → fluid shifts into the bowel (early) → then insulin surge (late)

Teaching — mostly diet (this is the tested part)

• Small, frequent meals (5–6/day)
• High protein, high fat, LOW simple carbohydrate — no sweets/sugary drinks
• NO fluids WITH meals — drink 30–60 min before or after
• Lie down (recumbent/semi-recumbent) 20–30 min after meals to slow gastric emptying
• Avoid very hot/cold foods; symptoms usually improve over months

• Functional disorder — no structural damage or inflammation (vs IBD!). Brain-gut axis; often stress-linked; women > men
• S/S: abdominal pain relieved by defecation, altered bowel pattern (IBS-C/D/mixed), bloating, mucus. NO bleeding, weight loss, fever, or anemia — those are red flags for something else.
• Dx: Rome criteria after ruling out organic disease
• Management: food diary, low-FODMAP diet trial, avoid gas-formers/caffeine/alcohol; soluble fiber for IBS-C; loperamide for IBS-D; antispasmodics; stress management/CBT

• Diverticula = pouches herniate through weak colon wall (usually sigmoid). Low-fiber diet + chronic constipation + ↑pressure.

• Acute flare: bowel rest, antibiotics, pain control; NO colonoscopy, barium enema, laxatives, or enemas (perforation risk)
• Complications: abscess, fistula, obstruction, perforation → peritonitis

• Risks: age (screen at 45), polyps, IBD, family hx/FAP/Lynch, red/processed meat, low fiber, alcohol, smoking, obesity
• Left/sigmoid/rectal: change in bowel habits, pencil/ribbon stools, bright red blood, obstruction
• Right-sided: vague pain, occult blood, iron-deficiency anemia, fatigue, RLQ mass
• Unexplained iron-deficiency anemia in an older adult = colon cancer until proven otherwise
• Colonoscopy = gold standard (sees + removes polyps); CEA monitors treatment (not screening); surgery ± colostomy, chemo/radiation

• Constipation: fiber 25–35 g/day, fluids, exercise, don't ignore the urge; bulk-forming laxative with full glass water; cardiac clients avoid straining/Valsalva → give stool softeners
• Diarrhea: watch dehydration, hypokalemia, metabolic acidosis; skin barrier care; C. diff = contact precautions + soap-and-water handwashing (alcohol gel doesn't kill spores)
• Fecal incontinence: bowel training (consistent timing), pelvic floor exercises, fiber, skin protection, dignity

• Hemorrhoids: dilated rectal veins from straining/constipation/pregnancy. Conservative: high fiber + fluids, sitz baths, topical agents, stool softeners; post-hemorrhoidectomy: pain expected, sitz baths, prevent constipation, watch bleeding/urinary retention
• Pilonidal cyst: infected sinus in the tailbone (sacrococcygeal) area; I&D + wound packing (heals by secondary intention); keep clean/dry/hair-free, avoid prolonged sitting

• Autoimmune: gluten → attack on small-bowel villi → villous atrophy → malabsorption
• S/S: diarrhea, steatorrhea (fatty foul floating stools), weight loss, bloating, anemia, dermatitis herpetiformis (itchy blistering rash)
• Dx: tTG-IgA → confirm with EGD + biopsy. Keep eating gluten until testing done
• Tx = lifelong strict gluten-free diet. Avoid BROW: Barley, Rye, Oats (cross-contam), Wheat. Safe: rice, corn, potato, quinoa. Read every label; separate toaster.

• 5-ASA (sulfasalazine): with food + water, orange urine normal, take folic acid, sunscreen; sulfa allergy = contraindicated
• Corticosteroids: flares only, taper. Biologics (infliximab): TB test first, infection risk

Stoma assessment — first priority every time

• Healthy: pink-red, moist, shiny; mild edema + tiny bleeding when cleaned = normal early
• Pale = anemia; dusky/purple/black = ischemia → surgical emergency, report immediately

• Empty pouch at ⅓ full; change wafer q3–7 days or if leaking; cut opening ~1/8" larger than stoma; measure each change (shrinks over 6–8 wk)
• Ileostomy: avoid blockage foods — popcorn, nuts, seeds, corn, celery, raw cabbage, dried fruit, mushrooms; chew well
• Odor/gas: limit onions, eggs, fish, cabbage, beans, carbonation; support body image + ostomy groups

• Assess distal to the injury/cast, compare both sides, q1h ×24h then routinely
• Pain — disproportionate, unrelieved by opioids, worse with passive stretch = danger
• Pulses — dorsalis pedis, posterior tibial; compare bilaterally
• Pallor — color/temperature distal to injury (cool, pale = arterial compromise)
• Paresthesia — numbness/tingling = early nerve ischemia
• Pulselessness — late, ominous
• Paralysis — inability to move = late/severe

Fractures

• Types: open (skin broken — infection/osteomyelitis risk), closed, comminuted, greenstick, spiral (suspect abuse), pathologic
• Hip fracture: affected leg shortened, externally rotated, painful; often elderly post-fall; surgery (ORIF/arthroplasty) + early mobilization; VTE + pneumonia + skin prevention
• Care: immobilize, neurovascular checks, ice + elevate early, pain control, traction if ordered

Casts

• Fiberglass dries 15–30 min; plaster 24–72 hr (handle with palms, keep dry, uncovered to dry)
• Elevate above heart first 24–48 hr; ice; never insert objects; report drainage/odor/hot spots (infection), or blue/cold/numb digits + unrelieved pain (compartment syndrome)
• Petal rough edges; teach isometric exercises to prevent muscle atrophy

• Golden rules: weights hang FREELY (never resting on floor/bed), never remove without an order, maintain alignment + counter-traction, ropes knot-free on the pulleys
• Pin care: serosanguineous drainage = normal (don't remove crust); purulent + redness + warmth + pin loosening = infection → report; clean per protocol (NS/chlorhexidine, not povidone-iodine)

• Osteomyelitis: bone infection (often after open fracture/surgery/bacteremia). Constant deep throbbing bone pain, local redness/warmth/swelling, fever, ↑ESR/CRP/WBC; MRI = best early (X-ray changes lag 10–21 days)
• Tx: long-term (4–6+ wk) IV antibiotics, possible surgical debridement, immobilize, pain control
• Avascular necrosis: loss of blood supply → bone death (common in hip fracture, chronic steroids); pain + ↓ROM → may need arthroplasty

• ↓bone density → fragility fractures (hip, wrist, vertebrae → kyphosis, height loss). Risks: postmenopausal, thin, smoking, steroids, low Ca/D, inactivity, alcohol
• Dx: DEXA scan (T-score ≤ −2.5). Prevention/tx: Ca + vitamin D, weight-bearing exercise, fall prevention
• Bisphosphonates (alendronate): take on empty stomach with full glass of water, stay upright 30 min (esophagitis risk), before other food/meds

• Immediate priority = hemorrhage: keep a tourniquet at bedside; if the stump bleeds, apply direct pressure + tourniquet, notify surgeon
• Phantom limb pain is REAL — treat it (don't dismiss); gabapentin, mirror therapy, etc.
• Positioning: elevate stump on pillow first 24 hr for edema, then avoid prolonged elevation/pillows to prevent flexion contracture; prone periodically (BKA/AKA); figure-8 stump wrapping to shape for prosthesis
• Body image support, PT, monitor incision for infection/healing (especially diabetics/PAD)

• Sprain = ligament; strain = muscle/tendon; dislocation = joint out of alignment (neurovascular check, reduce, immobilize)
• RICE: Rest, Ice (first 24–48 hr, 20 min on/off), Compression, Elevation; ice not heat early (heat later for chronic)