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

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

Specializes in Medsurg RN/MSN-FNP.

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. 

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!

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