Surgical Step-Down

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    Hey everyone, I'm a newbie that will be starting orientation for the Surgical Step-Down unit April 10th. Can anyone share any words of wisdom for what to expect out of orientation and a Surgical Step-Down floor in general? I'll be working days and the NM told me that they get very busy with admissions... They primarily do bariatric surgeries on the floor that I've been hired for, but there is also a mix of Med/Surg patients. Depending on their acuity, I could get anywhere from 4-7 patients...

    I'm very happy and can't wait to start, but I'm also nervous. My biggest fear is making a medical error with medication or anything else. I originally applied for a full-time night position, but ended up getting a part-time day position on this particular unit. It's been 10 months since graduating nursing school, so I'm so grateful for this opportunity and I really want to be successful. I also think it will be better for me to start out as a part-timer; I don't feel as overwhelmed.

    Ninja_RN likes this.

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  2. 3 Comments...

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    Hi there! I started as a new grad on a surgical/step down unit and I love it (it's been eight months now that I've worked on my floor). It can be extremely overwhelming at times, especially working day shift, but you will learn a lot and your organizational skills really pick up. There is so much that you'll learn, but I'll try to give you a couple of the routine things that I've learned in my short time

    1) The incentive spirometer is one of the most important pieces of equipment that youíll see. Post-op patients need to be using this every six to ten minutes (or one a commercial) while awake. This machine helps to keep the lungs strong and prevent fluid from settling and causing pneumonia. Iíd say about 95% of the time when patients on our floor develop a fever, itís because theyíre not using their IS enough. Reinforce teaching and encourage use, and temps will usually return back to normal. This little device is an integral part of surgical recovery.

    2) Ditto flowtrons. Generally, if theyíre in bed and itís not contraindicated for some reason, flowtrons are on. Period. If a patient doesnít like them, just educate them on how itís for DVT prophylaxis Ė theyíre usually amenable after that (no one likes blood clots!), and if theyíre not, you just put in your note that you educated the patient on flowtron use and they refused.

    3) Triple check your PCAs. This is one thing that Iíve become neurotic about. If I have patients with a PCA, Iíll grab the narc keys and verify the syringe and rates first thing. When I hang a new syringe or change the rate, I always have another nurse double-check me. We recently had a nurse on our floor mistakenly hang a Dilaudid syringe instead of Morphine in a PCA (and the hourly lockout was entered at the morphine rate of 7mg/hr) Ė the patient ended up having to be Narcaníed and the RN was suspended. Itís real easy to overlook things when youíre on a busy floor, but PCAs are one thing to definitely take the time to triple check.

    4) Your fresh post-op bariatrics are going to be nauseous. This is normal. However, if they vomit, thatís bad. Call the doctor right away.

    5) Try to get a pain management routine down. Surgical patients are generally in a lot of pain. You canít completely get rid of their pain most of the time, but we want them to generally be at a 3 to 4 at most ideally on a scale of 1 to 10. Also, an hour or two prior to change of shift, check your patientís pain levels, explain that change of shift is coming up, and medicate if needed prior so that the oncoming nurse isnít slammed with 6 people asking for pain meds at once. Your change of shift RNs will appreciate it!

    6) A good brain sheet is going to help you out so much. Esme has some awesome ones that she links if you do a search, but organization is huge on a med/surg floor.

    7) Finally, being empathetic and working hard for the patient can help make up for your lack of experience. Show caring and kindness, and help that patient as much as you can through their recovery. Go that extra mile. Even though you donít have the experience that other nurses have, that patient will think that youíre a great nurse.

    All in all, itís a very hectic job, but I personally love it and I think youíll learn a lot working on a surgical floor. Hopefully some of the more experienced nurses can offer some more tips Ė and utilize the experienced nurses at your jobs, too! They know a hell of a lot, and if you can find your ďYoda,Ē learn everything that you can from them. If youíre concerned about something, but not sure whether itís a definite cause for concern, have someone with more experience come in and give their opinion. Best of luck to you!
    Last edit by alibee on Mar 26, '13
    Ninja_RN, nrnr10new, and mitral like this.
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    And also, I&Os are very important on a surgical floor. A lot of times, patients will be "dry" when they come up from the PACU. Watch their urine output, and let the doctor know if it's low so that they can put in an order for us to bolus if needed. Watch for s/s of hypovolemia (check pulses, look out for low BP, and watch urine output).
    Ninja_RN and nrnr10new like this.
  5. 0
    alibee - you're awesome! Thank you so much, I have a much better idea of what to expect now. I'm actually going to print this out and keep it with my orientation notebook! =)

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