Medical Surgical Nursing Notes: High-Yield Disorders, ABG, Shock and Burns for NORCET

These medical surgical nursing notes summarise the disorders, values and nursing priorities that carry the most marks in AIIMS NORCET, staff nurse and nursing officer exams. They follow the system-wise approach of Brunner and Suddarth and Lewis, with tables for quick recall and clear nursing management points.

Medical-surgical nursing is usually the largest single subject in nursing officer papers, and many questions are clinical scenarios that ask for the first or priority action. Learn the normal values first, then the “what to do first” logic for each emergency.

How to use these medical surgical nursing notes

Start with fluid, electrolyte and ABG basics, because they explain shock, burns, renal failure and diabetic emergencies. Normal physiology is in the anatomy and physiology notes for nursing, and the drugs used below are explained in the pharmacology notes for nursing.

Fluid and electrolyte imbalances

Electrolyte	Normal	Low: key signs	High: key signs
Sodium	135 to 145 mEq/L	Confusion, seizures, headache	Thirst, restlessness, dry mucosa
Potassium	3.5 to 5.0 mEq/L	Muscle weakness, flat T wave, U wave	Tall peaked T wave, wide QRS, arrhythmias
Calcium	8.5 to 10.5 mg/dL	Tetany, Chvostek and Trousseau signs, prolonged QT	Muscle weakness, kidney stones, constipation
Magnesium	About 1.5 to 2.5 mEq/L	Tremors, hyperreflexia, arrhythmias	Loss of deep tendon reflexes, respiratory depression

• IV potassium is never given as an IV push; it is always diluted and infused slowly (commonly not more than 10 mEq/hour through a peripheral line), with cardiac monitoring at higher rates.
• Emergency treatment of hyperkalaemia: IV calcium gluconate (protects the heart), insulin with dextrose and salbutamol nebulisation (shift potassium into cells), then removal by resins, diuretics or dialysis.
• Correct chronic hyponatraemia slowly to avoid osmotic demyelination.

ABG interpretation

Parameter	Normal
pH	7.35 to 7.45
PaCO2	35 to 45 mmHg
HCO3	22 to 26 mEq/L
PaO2	80 to 100 mmHg
SaO2	95 to 100 percent

1. Look at pH: below 7.35 is acidosis, above 7.45 is alkalosis.
2. Look at PaCO2: if it moves opposite to pH (high CO2 with low pH), the cause is respiratory.
3. Look at HCO3: if it moves in the same direction as pH (low HCO3 with low pH), the cause is metabolic.
4. Check compensation: if pH is normal but both values are abnormal, the disorder is fully compensated.

Example: pH 7.30, PaCO2 52 mmHg, HCO3 25 mEq/L is uncompensated respiratory acidosis (as in COPD exacerbation or opioid overdose). Diabetic ketoacidosis causes metabolic acidosis with Kussmaul breathing; vomiting and NG suction cause metabolic alkalosis; anxiety-related hyperventilation causes respiratory alkalosis.

Shock

Type	Cause	Distinguishing features
Hypovolaemic	Haemorrhage, burns, severe vomiting and diarrhoea	Cold clammy skin, tachycardia, low urine output
Cardiogenic	Myocardial infarction, heart failure	Pulmonary congestion, raised jugular venous pressure
Septic (distributive)	Severe infection	Fever or hypothermia, warm skin early, raised lactate
Anaphylactic (distributive)	Drugs, insect stings, food	Stridor, wheeze, urticaria, angioedema
Neurogenic (distributive)	Spinal cord injury above T6	Hypotension with bradycardia, warm dry skin
Obstructive	Tension pneumothorax, cardiac tamponade, massive pulmonary embolism	Distended neck veins, sudden collapse

• Stages: initial, compensatory, progressive, refractory (irreversible).
• MAP target is usually 65 mmHg or more; urine output at least 0.5 mL/kg/hour.
• Anaphylaxis first-line drug: IM adrenaline 1:1000 (1 mg/mL), 0.5 mg in adults into the anterolateral thigh, repeated after 5 minutes if needed.

Burns

Area (adult, rule of nines)	Percent TBSA
Head and neck	9
Each upper limb	9
Anterior trunk	18
Posterior trunk	18
Each lower limb	18
Perineum	1

In children the head is proportionally larger, so the Lund and Browder chart is more accurate. The patient’s palm with fingers is about 1 percent TBSA. Superficial (first-degree) burns are not counted.

Parkland formula: 4 mL x body weight (kg) x percent TBSA of Ringer’s lactate in the first 24 hours, counted from the time of the burn. Half is given in the first 8 hours and half in the next 16 hours.

Worked example: 60 kg adult with 40 percent burns. 4 x 60 x 40 = 9,600 mL. Give 4,800 mL in the first 8 hours (600 mL/hour) and 4,800 mL over the next 16 hours (300 mL/hour). Titrate to an adult urine output of about 0.5 mL/kg/hour.

• Depth: superficial (red, painful, no blisters), partial thickness (blisters, very painful), full thickness (white or leathery, painless because nerve endings are destroyed).
• Suspect inhalation injury with facial burns, singed nasal hair, hoarseness or carbon-stained sputum; airway comes first.
• Circumferential full-thickness burns may need escharotomy. Curling’s ulcer is a stress ulcer seen after major burns.

Perioperative nursing

Pre-operative

• Informed consent is obtained by the surgeon; the nurse may witness the signature and must ensure it is signed before pre-medication.
• Fasting (ASA guidance for healthy patients): clear fluids up to 2 hours, breast milk 4 hours, light meal or non-human milk 6 hours before anaesthesia.
• Remove jewellery, dentures and nail polish; ask the patient to void; complete the safe surgery checklist.

Post-operative

• Airway is the first priority in the recovery room; keep the unconscious patient in the lateral position.
• Monitor vital signs frequently, pain, wound drainage and urine output.
• Atelectasis is a common early pulmonary complication: encourage deep breathing, incentive spirometry and early ambulation.
• Wound dehiscence or evisceration: cover with sterile saline-moistened dressing, place in low Fowler’s with knees flexed, and inform the surgeon.
• Malignant hyperthermia is treated with dantrolene.

Critical care basics

Glasgow Coma Scale	Score
Eye opening	1 to 4
Verbal response	1 to 5
Motor response	1 to 6
Total	3 to 15; 8 or less suggests severe injury and need for airway protection

• Raised intracranial pressure: Cushing’s triad is hypertension with widened pulse pressure, bradycardia and irregular respiration. Keep head of bed at about 30 degrees with neck in neutral position.
• Ventilator modes include assist control, SIMV, pressure support and CPAP. PEEP keeps alveoli open at the end of expiration.
• High pressure alarm: secretions, coughing, biting the tube, kinked tubing, bronchospasm. Low pressure alarm: disconnection or cuff leak.
• VAP prevention bundle: head of bed 30 to 45 degrees, daily sedation interruption, oral care, DVT and stress ulcer prophylaxis.
• Endotracheal suctioning: pre-oxygenate and limit each pass to about 10 to 15 seconds.

Hypertension and myocardial infarction

JNC 7 category	Systolic (mmHg)	Diastolic (mmHg)
Normal	Below 120	Below 80
Prehypertension	120 to 139	80 to 89
Stage 1 hypertension	140 to 159	90 to 99
Stage 2 hypertension	160 or more	100 or more

The 2017 ACC/AHA guideline uses lower cut-offs (stage 1 from 130/80). Management includes salt restriction, weight loss, exercise, no smoking and limited alcohol, plus drugs. In a hypertensive emergency, BP is lowered gradually, not to normal at once.

Myocardial infarction: crushing chest pain lasting more than 20 minutes, not relieved by rest or nitroglycerin, often radiating to the left arm or jaw. Troponin is the most specific marker. ECG shows ST elevation in STEMI.

• Immediate care: aspirin (chewed), nitroglycerin if BP allows, oxygen only if SpO2 is below 90 percent, morphine for unrelieved pain, and urgent reperfusion.
• Reperfusion targets: door-to-needle within 30 minutes for thrombolysis and door-to-balloon within 90 minutes for primary PCI.
• Arrhythmias, especially ventricular fibrillation, are the commonest cause of early death.
• Inferior MI: leads II, III, aVF. Anterior MI: V1 to V4.

In heart failure, left-sided failure causes pulmonary congestion (crackles, dyspnoea), while right-sided failure causes systemic congestion (pedal oedema, raised JVP, hepatomegaly). Weigh daily; a gain of more than about 1 kg in a day suggests fluid retention.

Stroke

• Ischaemic stroke is far more common than haemorrhagic stroke.
• Recognise with BE FAST: Balance, Eyes, Face drooping, Arm weakness, Speech difficulty, Time to call.
• A non-contrast CT scan is done first to rule out haemorrhage before thrombolysis. IV alteplase is given within 4.5 hours of symptom onset in eligible patients.
• Left hemisphere stroke: right-sided weakness and aphasia. Right hemisphere stroke: left-sided weakness, neglect and poor judgement.
• Screen swallowing before giving anything by mouth; position to prevent contractures and pressure injury.

COPD and asthma

Feature	COPD	Asthma
Airflow limitation	Persistent, progressive	Variable, reversible
Main risk	Smoking, biomass smoke	Allergens, atopy, triggers
Spirometry	Post-bronchodilator FEV1/FVC below 0.70	Significant improvement after bronchodilator
Oxygen target	SpO2 88 to 92 percent	SpO2 94 to 98 percent

• Teach pursed-lip breathing and the tripod position for COPD.
• Salbutamol is the reliever; inhaled corticosteroids are controllers. Rinse the mouth after inhaled steroids to prevent oral candidiasis.
• A “silent chest” in acute severe asthma is a danger sign of minimal air movement.

Diabetes mellitus

Test	Diabetes	Prediabetes
Fasting plasma glucose	126 mg/dL or more	100 to 125 mg/dL
2-hour OGTT (75 g)	200 mg/dL or more	140 to 199 mg/dL
HbA1c	6.5 percent or more	5.7 to 6.4 percent

• Hypoglycaemia (below 70 mg/dL): if conscious, give 15 g fast-acting carbohydrate and recheck in 15 minutes; if unconscious, IV dextrose or IM glucagon.
• DKA: hyperglycaemia, ketosis, metabolic acidosis, Kussmaul breathing and fruity breath; usually type 1. HHS: very high glucose (often above 600 mg/dL) and high osmolality with little ketosis; usually type 2 in older adults.
• DKA treatment order: IV fluids first (0.9 percent saline), then IV regular insulin infusion with potassium monitoring and replacement; add dextrose when glucose falls to about 200 to 250 mg/dL.
• Foot care: inspect daily, never walk barefoot, cut nails straight.

Renal failure

• Acute kidney injury may be pre-renal (low perfusion), intrarenal (nephrotoxins, acute tubular necrosis) or post-renal (obstruction).
• Oliguria: urine output below 400 mL/day; anuria: below about 100 mL/day.
• CKD stages by GFR (mL/min/1.73 m2): stage 1 is 90 or more, stage 2 is 60 to 89, stage 3 is 30 to 59, stage 4 is 15 to 29, stage 5 is below 15 (end-stage).
• Diet: restrict sodium, potassium, phosphate and fluid; daily fluid allowance is commonly the previous day’s urine output plus about 500 mL.
• AV fistula: feel for a thrill and listen for a bruit; never take BP or blood from that arm.
• Cloudy peritoneal dialysis effluent suggests peritonitis. Anaemia in CKD is due to reduced erythropoietin.

Other high-yield disorders

• Peptic ulcer: H. pylori and NSAIDs are major causes. Duodenal ulcer pain is often relieved by food; gastric ulcer pain often worsens after meals.
• Cirrhosis: hepatic encephalopathy shows asterixis; lactulose reduces ammonia.
• Acute pancreatitis: raised serum amylase and lipase; Cullen’s and Grey Turner’s signs indicate haemorrhage.
• Thyroidectomy: watch for hypocalcaemia (tetany), laryngeal nerve injury and airway obstruction; keep a tracheostomy set and calcium gluconate at the bedside.
• Fractures: compartment syndrome shows pain out of proportion, pallor, paraesthesia, pulselessness and paralysis; fat embolism follows long bone fractures.

Oncology basics

• Staging uses the TNM system: Tumour size, Node involvement, Metastasis.
• Neutropenic patients need protective measures: strict hand hygiene, no fresh flowers or raw foods, and prompt reporting of fever.
• Chemotherapy is prepared in a biological safety cabinet with PPE; cytotoxic waste goes in the yellow category. Stop the infusion at once if a vesicant extravasates.
• Radiation therapy: do not wash off skin markings and avoid applying creams or heat to the treated area unless prescribed.
• Tumour lysis syndrome: hyperkalaemia, hyperphosphataemia, hyperuricaemia and hypocalcaemia.

Quick revision points

1. Peaked T waves: hyperkalaemia. U waves: hypokalaemia.
2. First drug in hyperkalaemia with ECG changes: IV calcium gluconate.
3. Trousseau and Chvostek signs: hypocalcaemia.
4. Normal PaCO2: 35 to 45 mmHg.
5. Neurogenic shock: hypotension with bradycardia.
6. Anaphylaxis drug of choice: IM adrenaline.
7. Parkland formula: 4 mL x kg x percent TBSA in 24 hours, half in the first 8 hours.
8. Each lower limb in adult rule of nines: 18 percent.
9. GCS of 8 or less: protect the airway.
10. Cushing’s triad: raised ICP.
11. Most specific cardiac marker: troponin.
12. Alteplase window for ischaemic stroke: within 4.5 hours.
13. COPD target SpO2: 88 to 92 percent.
14. HbA1c for diabetes: 6.5 percent or more.
15. First step in DKA: IV fluid resuscitation.
16. No BP measurement on the AV fistula arm.
17. Post-thyroidectomy tetany: hypocalcaemia from parathyroid injury.

Pair these notes with the fundamentals of nursing notes for procedures and the first aid and emergency nursing notes for CPR and trauma. For subject planning, see the NORCET preparation strategy.

Concept RNA teaches medical-surgical nursing in depth in its AIIMS NORCET courses and staff nurse and nursing officer courses. Test clinical reasoning with the NORCET test series and staff nurse test series, and grab the free nursing PDF notes.

Frequently asked questions

Why is medical-surgical nursing so important for NORCET?

It usually forms the largest share of nursing officer papers, and many clinical questions from other subjects also draw on med-surg concepts such as shock, ABG and fluid balance.

Which book should I use for medical surgical nursing?

Brunner and Suddarth’s Textbook of Medical-Surgical Nursing and Lewis’s Medical-Surgical Nursing are standard references. Use one for concepts and these notes for rapid revision.

How do I answer priority questions?

Apply airway, breathing and circulation first, then safety, then the condition-specific action. Prefer assessment before intervention unless the patient is in immediate danger.

Which med-surg topics are most frequently asked?

Fluid and electrolytes, ABG, shock, burns, MI, stroke, diabetes, COPD and asthma, renal failure, perioperative care and critical care basics such as GCS and ventilator alarms.