New grad to post op Med surg/ What to expect?

[bluewhale3]

Gonna be a little bit long so please bear with me!

Hi all I am a new grad to a post op med surg floor. I've only been only been on the floor for 4 days but feeling overwhelmed. So far I've been taking 2 out of the 4 patients and I am struggling with time management and charting, understanding what to expect, to the point where my preceptor does a lot for my two patients. I have several questions so please answer whichever ones you can. A few things I've noticed:

-I don't think we work with post op orthopedic surgeries because the hospital has an ortho floor.

-So far it appears the pt ratio is 4:1, but I will be working night shifts after I'm off orientation so I'm expecting that to change

-We do get post op transplant and bariatric patients. So far I've seen post op lung lobectomies for cancer, Wipples, grastrectomy. We also get post op tele patients. I heard they do blood transfusions often.

-Drains that I've seen are chestubes, bili and JP drains, NG tubes, foleys. PCA pumps, Epidural PCAs

My questions are:

1.) Complications, what to expect, meds , tips, tricks, or anything that you can offer me about those mentioned above would be much appreciated! I've never worked with this patient population before so I don't know what to expect.

2.) Those who have worked on a similar unit, what other surgeries should I learn about? I want to study as much as I can about this so that I don't have to waste time looking them up during work becuase my time management already sucks and I always feel behind.

3.) Some meds that I should be aware of? pain meds, treatment meds, etc.

4.) Labs? What are some big lab values that I should monitor for? Right now I'm trying to focus on sepsis but what other complications and lab values/components are there that would raise red flags.

5.) I know early ambulation is important and we follow the ERAS protocol (Enhansed recovery after surgery), but the patient is in SO MUCH PAIN, how do I know when it's not appropriate to push/encourage them? I hesitate with pushing them too much

Basically just anything and everything that you can throw at me, I would really appreciate. Just being a nurse in general. I still feel like a nursing student with my preceptor monitoring my every move becuase I am still making mistakes and I really appreciate them for that. Thank you so much allnurses community!

[Scottb88]

Hey, I will try to answer some questions.

1. Make sure to find out from other nurses, charge nurses, or doctors what they want from the documentation when it comes to chest tubes, thoracic surgeries etc. I worked in Pulm/Thoracic Intermediate Care/Thoracic surgery as my first nursing job. When it comes to drains/chest tubes some doctors may want output documented q4, and this should be specified in the order, but it isn't always. If you have the extra time, and its NOT specified, then do it anyways. With chest tubes, the biggest thing I would see is that by nature, chest tubes are very easy to pull out. If this happens, the patient may be at risk for pneumothorax. Removal of chest tubes can sometimes require two nurses so that one can immediately apply an occlusive dressing. As far as epidurals and PCA's, make sure the settings are right, and that its documented as frequently as your work setting requires, and that you know exactly what the protocol for disposing of the used PCA cassette is. You don't want to ever have to be accused of stealing narcotics as a nurse, its embarrassing knowing that you would never do that and having to explain yourself. When the order to remove a foley catheter is placed, especially after epidural medication, make ABSOLUTELY sure that you are on top of when that patient voids, and if you have the time, witness it yourself. If there is any question, do a bladder scan on ANYBODY. Inability to void following catheter removal is a serious thing, and easily missed, particularly when half of a discharge has been started but not completed between shifts. 

2. As far as surgeries go, the biggest thing is knowing the order set. Make sure you know the orders, and the red flags of procedures. Such as Lobectomy with chest tube, chest tube is not draining, the seal is broken.. etc. 

3. Be VERY aware and on the alert for medications like Fentanyl. If a patient you have on the FLOOR has a PRN for fentanyl, it could be from a previous order set, like in the PACU, where they are prepared for full monitoring, and use heavy hitters like that drug. Fentanyl is a scary drug, make sure you know where the medication order came from before you give it. 

4. Rounding NPs, PA's, and MD's view the daily CBC/BMP. If you have a critical lab value, then report it. Be VERY AWARE of patients on diuretics, and their potassium levels. VERY EASY to miss the potassium replacement protocol on patients receiving diuretics. 

5. Pain control and ambulation is an art. Remember that patients in extreme post-surgical pain may only get to a comfortable level that is tolerable after pain meds. If your patient is obtunded from too many pain medications, then ambulation is not a good idea. They need to be at a level that is tolerable, or makes them feel normal, to where they can willingly ambulate or whatnot. When you get report, ask when the patient last got their medication or look it up. Find out how much they have been requiring. If you know PT is going to work with them, but the patient hasn't received pain meds all day, it might be because their pain is triggered by movement. Often patients won't express their need for medication, for various reasons. Also remember in the hospital as a patient, its very easy to become disoriented or delirious. Patient's are subjected to lack of sleep, narcotic medications, and their underlying condition, they may seem coherent, but may not totally be. Ask harder questions than "What hospital are you at?", to determine overall mental status. 

Finally, one thing I can recommend any nurse, is spending some time furthering your knowledge on medication. The bedside prioritization will come with time, but understanding medications and what they can cause and WHY they are given will help you SO MUCH in making nursing decisions. If your patients HR is 55 you might not want to give a beta blocker, ask the doctor. This will not always be specified. 

[bluewhale3]

On 9/13/2020 at 4:33 PM, Scottb88 said:

Hey, I will try to answer some questions.

1. Make sure to find out from other nurses, charge nurses, or doctors what they want from the documentation when it comes to chest tubes, thoracic surgeries etc. I worked in Pulm/Thoracic Intermediate Care/Thoracic surgery as my first nursing job. When it comes to drains/chest tubes some doctors may want output documented q4, and this should be specified in the order, but it isn't always. If you have the extra time, and its NOT specified, then do it anyways. With chest tubes, the biggest thing I would see is that by nature, chest tubes are very easy to pull out. If this happens, the patient may be at risk for pneumothorax. Removal of chest tubes can sometimes require two nurses so that one can immediately apply an occlusive dressing. As far as epidurals and PCA's, make sure the settings are right, and that its documented as frequently as your work setting requires, and that you know exactly what the protocol for disposing of the used PCA cassette is. You don't want to ever have to be accused of stealing narcotics as a nurse, its embarrassing knowing that you would never do that and having to explain yourself. When the order to remove a foley catheter is placed, especially after epidural medication, make ABSOLUTELY sure that you are on top of when that patient voids, and if you have the time, witness it yourself. If there is any question, do a bladder scan on ANYBODY. Inability to void following catheter removal is a serious thing, and easily missed, particularly when half of a discharge has been started but not completed between shifts. 

2. As far as surgeries go, the biggest thing is knowing the order set. Make sure you know the orders, and the red flags of procedures. Such as Lobectomy with chest tube, chest tube is not draining, the seal is broken.. etc. 

3. Be VERY aware and on the alert for medications like Fentanyl. If a patient you have on the FLOOR has a PRN for fentanyl, it could be from a previous order set, like in the PACU, where they are prepared for full monitoring, and use heavy hitters like that drug. Fentanyl is a scary drug, make sure you know where the medication order came from before you give it. 

4. Rounding NPs, PA's, and MD's view the daily CBC/BMP. If you have a critical lab value, then report it. Be VERY AWARE of patients on diuretics, and their potassium levels. VERY EASY to miss the potassium replacement protocol on patients receiving diuretics. 

5. Pain control and ambulation is an art. Remember that patients in extreme post-surgical pain may only get to a comfortable level that is tolerable after pain meds. If your patient is obtunded from too many pain medications, then ambulation is not a good idea. They need to be at a level that is tolerable, or makes them feel normal, to where they can willingly ambulate or whatnot. When you get report, ask when the patient last got their medication or look it up. Find out how much they have been requiring. If you know PT is going to work with them, but the patient hasn't received pain meds all day, it might be because their pain is triggered by movement. Often patients won't express their need for medication, for various reasons. Also remember in the hospital as a patient, its very easy to become disoriented or delirious. Patient's are subjected to lack of sleep, narcotic medications, and their underlying condition, they may seem coherent, but may not totally be. Ask harder questions than "What hospital are you at?", to determine overall mental status. 

Finally, one thing I can recommend any nurse, is spending some time furthering your knowledge on medication. The bedside prioritization will come with time, but understanding medications and what they can cause and WHY they are given will help you SO MUCH in making nursing decisions. If your patients HR is 55 you might not want to give a beta blocker, ask the doctor. This will not always be specified. 

Thank you SO MUCH Scottb88 for your time and being so thorough! I'm several weeks in and your suggestions apply SO MUCH! what you're saying about medications is so important I think I'll start lookig more thoroughly about medications now. So far I've mainly been looking up the procedures because there are so many that I don't know but I totally forgot about the importance of the medications too, especially like you said about furosemide. I'll start reading more about the red flags of the procedures too because I'm still not entirely familiar with those. I try to look at the labs and results but right now my time magement sucks so bad that it's just hard for me to take the time to look through the charts because I'm so task oriented ?. I'm really going to take your advice to work though. THANK YOU SO MUCH YOU'RE GREAT!

[Scottb88]

It's all going to depend also on the culture of your particular unit. Working on a floor as either a new nurse or also as a nurse with many years of experience or even as a NP who has a hard time finding a job in that will land you under a microscope. Being thorough or concerned about the details will never be the same as doing the safest thing, and sometimes doing the safest thing slows down discharge or whatever may be the case. You will see things that slow down the process such as ex: Orders are in, but they are clearly wrong. So then you have to call the doctor/midlevel and fix that, or get an order to fix it yourself. Likely, you will have to take a telephone order to fix it yourself. So just get comfortable with understanding med orders. I will tell you this... whatever happens don't let day to day discourage you because if you hyperfocus on ever minutia then it will drive you for lack of a better term crazy. Or definitely give you GAD. Don't be afraid to call the provider, because if you call them with confidence they won't yell at you, and if they do, then let that roll off your shoulder, its likely not because of you. But this is something they don't teach you in school. If you are calling a rounding doctor for an order, unless its pertinent to the situation, you don't need to give them a full SBAR. If its BP is 180 and they don't have a PRN then tell them that. If they are in post-op pain and the order was for some weak stuff, then just stick with procedure and pain level. When I came out of RN school, I went straight into quasi critical care, in pulm/thoracic. At the time I thought it was the craziest stuff ever, because it was a mix of medsurg/critical. Now I work in Med-surg after working after having taken some time off to get my NP and I can tell you med-surg is wayyy different. In med-surg having confidence in your decision and not fearing a doctor call is everything. Also in general, Internal-Medicine doctors are very chill, and you as the nurse know the immediate situation of your patient. 

[Majoraty, RN]

I'm almost at a year experience on a busy surgical unit where I've had 6:1 ratio many nights and my aide has 22 patients. (0/10 do not recommend). We get general, urological, and vascular surgeries. 

 

1.) This is incorporated in below answers:

2a.) Procedures: Colon resection, colostomy creation (and ostomy care), ureteral stent placement, TURP, cholecystectomy, appendectomy, nephrectomy

2b.) Skills: ostomy care, IV start, CBI, dressing changes (incl. wound vacs), NGT placement and care, perc drain care, JP drain care, CT care, doppler pulses.

3.) Meds: Pain meds - tylenol, ibuprofen, oxycodone, morphine, dilaudid, tramadol, toradol (be wary of Cr/kidney fxn). Abx - vanc (needs troughs drawn - policy varies), cefepime, ceftriaxone, flagyl (with the strongest packaging you've ever seen). General cardiac meds are common, as many folks have cardiac comorbidities - BB, ARBs, ACEIs, diuretics.

4.) Labs: Hgb - blood loss, especially when it's trending down post-op, or if it suddenly dips down. Black stools? Hematoma? Decrease in BP/increase in HR? // K+ - especially in kidney surgical pts K+ can get out of whack, can cause lethal arrhythmias. // WBC - naturally it goes up a little with surgery, but very high numbers paired with your VS changes can show worsening infection and may warrant sepsis workup. // Cr - especially if patient is not tolerating PO intake, don't want an AKI. And some of the imaging uses contrast, so don't want to use that with high Cr.

5.) Pain/ambulation: I am actually doing a research project on ERAS protocol right now. Many of my patients are in a good deal of pain, especially general surgery. Urology and vascular not so much (except amputations). As someone stated above, it's a balance. You will begin to get a feel for how much pain medicine is a lot for one person and nothing for another. Always use your judgement for patient safety and ABCs - watch for respiratory depression with pain meds, and if they're pressure is 80s/50s don't give the dilaudid. When ambulating, have them dangle ensure they're not dizzy/SOB/desatting/etc. Then stand at side of bed. Then they can walk.

**I remember feeling how you do now, and it's pretty amazing to see yourself grow and look back on how much better your time management is. Over time you'll learn about these things and you'll recognize more and more of the procedures, medications, complications. What I love about nursing in general but especially surgical is there's always something new. I really embrace this, and don't be afraid to ask questions! Learn what you can on your own time too but also balance that with non-nursing things in your life and do relaxing things you enjoy.

[Majoraty, RN]

On 9/13/2020 at 10:33 PM, Scottb88 said:

If a patient you have on the FLOOR has a PRN for fentanyl, it could be from a previous order set, like in the PACU, where they are prepared for full monitoring, and use heavy hitters like that drug.

Yes yes yes yes yes. Especially working nights, many orders don't get "cleaned up" and in my facility I as an RN cannot get rid of them. But in the MAR it'll say something like "PACU Level 2 If not controlled, advance to level 3..." or something like that. ALWAYS check this.