Surgical Step-Down

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 you'll 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. I'd say about 95% of the time when patients on our floor develop a fever, it's because they're 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 they're in bed and it's not contraindicated for some reason, flowtrons are on. Period. If a patient doesn't like them, just educate them on how it's for DVT prophylaxis - they're usually amenable after that (no one likes blood clots!), and if they're 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 I've become neurotic about. If I have patients with a PCA, I'll 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) - the patient ended up having to be Narcan'ED and the RN was suspended. It's real easy to overlook things when you're 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, that's 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 can't 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 patient's pain levels, explain that change of shift is coming up, and medicate if needed prior so that the oncoming nurse isn't 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 don't have the experience that other nurses have, that patient will think that you're a great nurse.

All in all, it's a very hectic job, but I personally love it and I think you'll learn a lot working on a surgical floor. Hopefully some of the more experienced nurses can offer some more tips - and utilize the experienced nurses at your jobs, too! They know a hell of a lot, and if you can find your "Yoda," learn everything that you can from them. If you're concerned about something, but not sure whether it's a definite cause for concern, have someone with more experience come in and give their opinion. Best of luck to you!

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).

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! =)

On 3/26/2013 at 8:16 AM, alibee said:

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 you'll 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. I'd say about 95% of the time when patients on our floor develop a fever, it's because they're 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 they're in bed and it's not contraindicated for some reason, flowtrons are on. Period. If a patient doesn't like them, just educate them on how it's for DVT prophylaxis - they're usually amenable after that (no one likes blood clots!), and if they're 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 I've become neurotic about. If I have patients with a PCA, I'll 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) - the patient ended up having to be Narcan'ED and the RN was suspended. It's real easy to overlook things when you're 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, that's 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 can't 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 patient's pain levels, explain that change of shift is coming up, and medicate if needed prior so that the oncoming nurse isn't 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 don't have the experience that other nurses have, that patient will think that you're a great nurse.

All in all, it's a very hectic job, but I personally love it and I think you'll learn a lot working on a surgical floor. Hopefully some of the more experienced nurses can offer some more tips - and utilize the experienced nurses at your jobs, too! They know a hell of a lot, and if you can find your "Yoda," learn everything that you can from them. If you're concerned about something, but not sure whether it's a definite cause for concern, have someone with more experience come in and give their opinion. Best of luck to you!

This was SO helpful !! Thank you! Any other tips now that it’s been years later? (Common meds/procedures/equipment) Starting on a surgical step down soon! ❤️ thanks in advance ! 

On 3/26/2013 at 8:16 AM, alibee said:

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 you'll 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. I'd say about 95% of the time when patients on our floor develop a fever, it's because they're 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 they're in bed and it's not contraindicated for some reason, flowtrons are on. Period. If a patient doesn't like them, just educate them on how it's for DVT prophylaxis - they're usually amenable after that (no one likes blood clots!), and if they're 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 I've become neurotic about. If I have patients with a PCA, I'll 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) - the patient ended up having to be Narcan'ED and the RN was suspended. It's real easy to overlook things when you're 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, that's 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 can't 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 patient's pain levels, explain that change of shift is coming up, and medicate if needed prior so that the oncoming nurse isn't 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 don't have the experience that other nurses have, that patient will think that you're a great nurse.

All in all, it's a very hectic job, but I personally love it and I think you'll learn a lot working on a surgical floor. Hopefully some of the more experienced nurses can offer some more tips - and utilize the experienced nurses at your jobs, too! They know a hell of a lot, and if you can find your "Yoda," learn everything that you can from them. If you're concerned about something, but not sure whether it's a definite cause for concern, have someone with more experience come in and give their opinion. Best of luck to you!

Thank you for posting this !