Learn Med-surg: GI, perioperative & oncology from scratch
Before this: Nursing fundamentals
1What this topic covers
This topic follows the patients of a surgical and oncology ward: GI bleeding, bowel obstruction, cirrhosis, pancreatitis and stomas; care before and after surgery; wounds; pain relief; cancer treatment; and burns.
Many of these patients deteriorate quietly. Bleeding can be hidden inside the abdomen, infection can occur without fever, and opioid overdose can hide behind a normal oxygen saturation. Learn the early signs.
2The gastrointestinal tract
GI bleeding. Haematemesis (vomiting blood), coffee-ground vomit and melaena (black, tarry stools) suggest an upper GI source; fresh red blood per rectum usually a lower one. Resuscitate first, using vital signs rather than the first haemoglobin, which may still be normal.
Bowel obstruction causes colicky pain, distension, vomiting and no stool or wind. Treatment starts with nil by mouth, a nasogastric tube and IV fluids. Constant pain, fever and a rigid abdomen suggest strangulation or perforation.
Cirrhosis leads to ascites, varices, bleeding problems, jaundice and hepatic encephalopathy. Lactulose is titrated to 2–3 soft stools a day, and sedatives are avoided.
Acute pancreatitis (mostly gallstones or alcohol) causes epigastric pain through to the back and a lipase or amylase over three times normal. Give goal-directed IV fluids and good analgesia, and restart eating early when tolerated.
Stomas. A healthy stoma is moist and red. Cut the appliance 2–3 mm larger than the stoma and empty the pouch when one third to half full. Ileostomy output is liquid, so dehydration is the main risk.
Self-check A new stoma is dark purple and dry on the first day after surgery. What does this suggest?
- A normal appearance that needs no action
- A poor blood supply that must be reported
- An allergy to the appliance
- High output from the stoma
Answer: A poor blood supply that must be reported. A healthy stoma is moist and red. A dusky or black stoma suggests ischaemia. Calling it normal delays treatment that may need surgery.
3Before and after surgery
Before surgery: the operating clinician obtains informed consent; patients fast (often clear fluids up to 2 hours and food up to 6 hours before); medicines such as anticoagulants and some diabetes drugs are managed as prescribed; and the WHO checklist is used in theatre.
After surgery, assess ABCDE. Typical complications by time:
- Hours: bleeding (tachycardia and falling blood pressure, even with a dry dressing), airway problems, urinary retention.
- Days 1–3: atelectasis, chest infection, ileus, delirium.
- Days 3–10: wound infection, anastomotic leak, wound dehiscence (most often days 5–10).
- Any time, often the first two weeks: DVT and pulmonary embolism.
If a wound opens and organs are visible, cover them with sterile saline-soaked dressings, bend the knees and call the surgeon. Never push them back.
4Wounds and pain
Wounds heal through haemostasis, inflammation, proliferation (red granulation tissue) and maturation. Healing needs protein, a moist wound bed, a good blood supply and no infection. Choose dressings by moisture: hydrogel adds moisture, alginate and foam absorb it.
Pain is what the patient says it is. Assess with a rating scale, give analgesia, then reassess. Combine drugs with different actions (multimodal analgesia) to reduce opioid needs.
Opioid safety: sedation rises before breathing slows, so monitor sedation as well as respiratory rate. Supplemental oxygen can hide hypoventilation. Only the patient presses a PCA button. Naloxone is titrated in small doses and may wear off before the opioid.
Self-check A patient on an opioid PCA is hard to rouse, with a respiratory rate of 10/min and SpO₂ 97% on oxygen. What is the most important conclusion?
- Opioid toxicity is likely despite the normal SpO₂
- The patient is safe because SpO₂ is normal
- The patient is simply sleeping well
- The patient needs a higher PCA dose
Answer: Opioid toxicity is likely despite the normal SpO₂. Oxygen keeps the saturation up while CO₂ rises. Increasing sedation is the warning sign; relying on SpO₂ alone is the classic mistake.
5Oncology and burns
Neutropenic sepsis: any patient who is unwell during the chemotherapy nadir (often 7–14 days after treatment) is treated urgently, with IV antibiotics within an hour, even without a high fever.
Tumour lysis syndrome: rapid cell death raises potassium, phosphate and uric acid and lowers calcium, damaging the kidneys. Prevention is hydration and allopurinol or rasburicase.
Chemotherapy safety: chemo-tested gloves and gowns, spill kits, care with body fluids for about 48 hours, and vincristine never intrathecally. For extravasation, stop the infusion and follow the policy.
Burns: estimate the area with the rule of nines (adult: head 9%, each arm 9%, front and back of trunk 18% each, each leg 18%, perineum 1%), counting only partial- and full-thickness burns. The Parkland formula estimates fluid for the first 24 hours:
fluid (mL) = 4 × weight (kg) × %TBSA
Give half in the first 8 hours from the time of the burn and half over the next 16 hours, then adjust to a urine output of about 0.5 mL/kg/h in adults.
Self-check In the Parkland formula, from when are the first 8 hours counted?
- From admission to the burns unit
- From arrival in the emergency department
- From the start of the first infusion
- From the time of the burn
Answer: From the time of the burn. Fluid loss starts at the injury, so the clock starts then. Counting from arrival delays the fluid the patient has already lost.
6A worked example
Decide what is most dangerous right now, then act.
Worked exampleFour hours after a bowel resection, Mr Janssen’s heart rate has risen from 84 to 118/min and his blood pressure has fallen from 132/80 to 92/56 mmHg. His abdomen is more distended and his wound dressing is dry. He has a PCA and says his pain is 6/10. What do you do?
1A rising heart rate and falling blood pressure soon after surgery suggest bleeding. A dry dressing does not exclude bleeding inside the abdomen.
2Check airway, breathing and saturation, then circulation: capillary refill, skin, urine output and drain output. Make sure there is IV access.
3Call the surgical team urgently using SBAR. Expect blood tests including crossmatch, fluids or blood as prescribed and possibly a return to theatre.
4Continue monitoring and pain assessment. Do not blame the tachycardia on pain without excluding bleeding first.
Answer Suspect internal bleeding: assess ABCDE, secure IV access, escalate urgently and monitor closely.
7Common mistakes and how questions look
- Trusting a normal first haemoglobin in an acute bleed.
- Waiting for a temperature of 38 °C before treating a neutropenic patient who is unwell.
- Relying on SpO₂ alone to judge opioid safety.
- Counting simple redness in the burn area, or starting the Parkland clock at arrival.
- Giving laxatives in a mechanical bowel obstruction.
Easy questions test terms and first-aid facts. Medium questions test reasons and monitoring. Hard questions present a deteriorating patient and ask for the first, safest action.
Learn it step by step in the appLearn it step by step in the app