Surgical nurse questions!

RNsRWe, ASN, RN · Jul 22, 2007

Hi, all,
I've been a nurse for 2 years, but mostly worked medical units. So, yesterday I am floated to a surgical floor, which was CRAZY! I have a few dumb questions:
1. Pt had a radical mastectomy, 7 hours in surgery, I get her at 1730. Surgeon calls at 2200, wondering if I looked at the incision, and how is the flap? (Huh? What flap? She did have a reconstruction). This pt was wrapped up like crazy, including abdominal binder, with 4 JP drains. Unwrapping all this would be like unwrapping the invisible man, plus I wouldn't think that one would be messing with the dressings so soon after surgery. What say you?
2. Most pts diets are "advance as tolerate", even for lady in #1 above. I realize she didn't have bowel surgery, but doesn't the bowel go to sleep with 7 hours of general anesthesia? I appreciate the docs giving the RN the room to decide, but it just surprised me. I guess I'm so used to medical patients who seem to be NPO if they have a wart or something. Any words of wisdom?
3. I had 3 post-surgical admits in 2 hours. One mastectomy, one TURP, and one hernia pt who couldn't keep his post-op sats up, had to go on BIPAP, get pulmonary consult, etc. Is this normal, or was I being taken gross advantage of? Each one had PILES of orders that I had to slog through. It just seemed a little much, esp for a floater.
It was interesting, but I'm pooped today! I have great respect for you folks working on surgical floors!
Oldiebutgoodie

None of these questions was dumb :)

In Scenario #1, I don't undo dressings s/p surgery unless I have a specific order to do so! Sometimes, I'll reinforce a messy, leaky dressing, but then I'll notify the doc if I see anything unusual there. If I want to actually change a dressing and don't have such an order, I'll call the doc and ask what he/she wants done. Sometimes it's "go ahead and do xxx dressing", sometimes it's "leave it be" or "reinforce PRN". Depends on doc and surgery done. As far as "looking at the incision", well....duh. If he wrapped the bejeezus out of it, NO I haven't seen the incision or flap! But of course if it's something that I CAN peak inside, I can report what I'm seeing. Doesn't sound like the MD had the most reasonable questions at that time.

Scenario #2: Depends again on the surgery and the type of anesthesia used. Advance-as-tolerated diets usually mean starting them on sips of water, seeing that they don't puke that up, moving to small amounts of clears, seeing that they don't puke THAT up, and working forward from there. And, of course, any amount of abdominal cramping, etc, means there's no moving forward. After a surgery, any surgery, you should be assessing for bowel sounds, and therefore if there aren't any (or are hypo) you'll probably be waiting a bit before advancing even to sips. Just using nursing judgment in most cases, unless doc specifically requests a particular diet plan. And even then, we use our judgment and call the doc to advance or NOT advance if he/she's made such an order.

Scenario #3: well, sometimes patients didn't read the "How to be a Model Recovery Patient" handbook, LOL! Yep, sometimes you'll be on the phone alot doing followups, getting consults, changing orders. On my unit, it's generally too much to have the floor nurses do it while still attending to patients, so usually it's the charge who does all the calls (but not always). I would say you were only being taken advantage of if the charge was sitting on his or her butt and HAD the time to do the calls, but passed it off on you. Otherwise, these fall into your lap. The orders should have been passed through charge as well, so you shouldn't be "slogging through" anything.....but that doesn't mean there aren't LOTS of new order and order changes post-operatively. Goes with the territory: what worked before surgery is now changed; any meds prior to surgery have to be renewed (because they do frequently change, and MD must order once again whatever he/she wants done post-op).

All in all, we try to keep floats to our floor from killing themselves (or someone else!) so assignments are supposed to be kept limited. However, for someone who floats to us alot, well, anything goes!

Thanks for the kudos, but it sounds like you deserve some yourself for surviving!

kell1566 · Jul 27, 2007

i definitely agree with the above post....we NEVER do the dressing postop the surgeon does it unless we have to reinforce it or its grossly leaking....then i usually call and ask.... you could peak tho I usually do.

in regard to diet....... we need an order from the docs but they make the decisions based on our assessments of bowel sounds, passing gas etc.....one time this guy had a TURP and they had him on reg full diet 6 hrs postop....... i called and said dont ui think you wanna start him on clears....... well pt claimed he was sooo hungry so doc ordered house diet and not even within 1 min of eating.... projectile vomiting haha... maybe the MD will listen next time.

definitely surgical pts are tough but its so exciting how diff people adapt after surgery and how some progress faster than others....i work on transplant floor for liver and kidneys and that is super neat!!! surgical is overwhelming but definitely awesome!! good luck for next time sounds like you did just fine today:monkeydance:

sweetspirit · Jun 26, 2008

1. Always check the flap!!!

2. Almost always even if is says Adv as Tol, I start out slow - ice chips then jello/Clear liquids. If they can handle it I'll move 'em up

3. Poor managing by the Charge Nurse especially because you were a floater - but yup that's my typical day!

Fiona59 · Jun 29, 2008

Pretty much the same in my world.

In regards to the dsg., we don't take it down until the next day. Reinforce if needed. Drain care as required. On some surgical patients there are even orders not touch the dressing for 24 hours or longer.

lovetoride · Jul 10, 2008

#1.. no I would not have taken down the dressing 5 hours later. I don't see this much, but when I have I've changed the dressing in the am with a bunch of fluffs just placed over the drain sites and the inc line, and held in place with that tight support bra. I would assess for draiange and reiforce as needed, unless it was a huge amt I would call.

#2 Our new bowel protocol is to keep on clix until they are passing gas in the orthopedic patients mostly. Others are usually specified. Others are just judgement on the pt and the surgeon and type of other surgery.

#3 And yes, you were taken advantage of imo. A medical nurse floating to a surgical unit should have gotten older post op pt's, not 3 fresh postops. It can't be avoided entirely though on a busy eves shift when alot of the pt's come back, but you should have gotten a lighter load for sure

RNperdiem, RN · Jul 10, 2008

In regards to #1. If there is a flap that needs checking, the doctors will have a dressing that can be lifted up to assess flap color and temperature and maybe a doppler pulse. The doctors usually go over with you exactly what to look out for and to call them with any changes to a flap. The off-going nurse is supposed to show the on-coming nurse what to do.

RN1989 · Jul 14, 2008

Any other dressing would be left alone. The TRAM flaps are high risk of dying, so it is important to see that they have good perfusion. They move tissue from the abdomen up to the breast. This is the only time I can think (at the moment) of that you would need to visualize the incision so soon. It was not appropriate to give you this patient since this is not a "normal" post op. Lots of potential litigation regarding mastectomy and reconstruction so following the protocol is imperative. Sounds like a normal day on a surgical floor. Glad you survived so well.

oldiebutgoodie, RN · Jul 14, 2008

Any other dressing would be left alone. The TRAM flaps are high risk of dying, so it is important to see that they have good perfusion. They move tissue from the abdomen up to the breast. This is the only time I can think (at the moment) of that you would need to visualize the incision so soon. It was not appropriate to give you this patient since this is not a "normal" post op. Lots of potential litigation regarding mastectomy and reconstruction so following the protocol is imperative. Sounds like a normal day on a surgical floor. Glad you survived so well.

OK, dumb question from the medical nurse... where IS the flap? Is the flap the newly constructed breast? If I had "unwound" all the dressings, (I think there was also an abdominal binder on her???) wound I rebind everything??

Geez, give me sepsis, cirrhosis, pneomonia, dehydration, etc... ;-)

Thanks for all your input!

Oldiebutgoodie

queenjean · Jul 19, 2008

Not dumb questions at all; I'm a medical floor nurse who floats occasionally to third, and I'm glad you asked these questions. I never knew about the issue with perfusion on the flap...

Did everyone else have so many fresh post op pts? When I (or any med nurse) float, they typically give me a larger team of "older" pts. That way I don't get admits (I work nights) unless it just gets really bad.

oldiebutgoodie, RN · Jul 19, 2008

Not dumb questions at all; I'm a medical floor nurse who floats occasionally to third, and I'm glad you asked these questions. I never knew about the issue with perfusion on the flap...
Did everyone else have so many fresh post op pts? When I (or any med nurse) float, they typically give me a larger team of "older" pts. That way I don't get admits (I work nights) unless it just gets really bad.

As I recall, that night the charge nurse had called in sick or something, and a float nurse was even being charge! It was nuts.

JBizzleRN, ADN, RN · Jul 24, 2008

3 post ops in two hours? LUCKY!! I work a Med/Surg floor on days and it's nthing for us to discharge 5 or 6 and get 3 back in the same hour...granted they are supposed to wait 30 minutes between admits, but that never happens if you tell them no they call the House Supervisor on you and then you get told you have to take the patient because they need the beds in PACU or the ER or wherever they are coming from.

So your other 6 patients are just sitting there waiting while you admit your other three patients :)..yeah we usually get loaded with 8 or 9 patients where I work, crazy...that's why i'm seeking new employement I love my job and I love nursing, but I do not like the fact I can't take the time to go "walk" my patient after surgery...or spend that little extra time with them talking....I didn't get into nursing just to push pills!!

As far as dressing go, on our floor we wil not change the dressing until told to do so by the doctor of the third postop day if it hasn't already been started. Now we do lift and dressings to assess the incisions during our assessments.