Sunday's Specialty - Med Surg

This week’s specialty comes to us from DreamingTree over at Med Surg Zone. She writes some great stories about her experiences as a Med Surg Nurse. After you’re done reading, jump on over to her blog to check out more!


Five years ago, I decided to go back to school for nursing. My background is in psychology, and I thought nursing would enable me to expand my career opportunities. In all honesty, it had never been my life's dream. In fact, throughout nursing school, I was the student who dreaded learning new lab skills. They often looked painful or awkward, and I could always see the potential for mortal harm to my patients if I screwed up. Classmates and family were used to me wondering if I should quit at any given moment. Gaining knowledge was great; potentially harming someone -- freaky. I share all of this because I was asked to write about my experiences as a med/surg nurse. I was the least likely in my class to become a med/surg nurse; and yet, here I am. I love it.

A medical/surgical floor is often touted as the best place for a brand new shiny nurse to begin. Why? A med/surg unit deals with a wide variety of patients: post-ops, chronic illness flare-ups (our "frequent fliers"), new onset illnesses (pneumonia, GI complaints, etc.), to name a few -- hence the name, Medical/Surgical. Our patients aren't sick enough to require continuous monitoring, but that could change at any point. We don't deal with many exciting procedures. Foley catheters, IV sticks, NG tubes, dressing changes, and some occasional suctioning are as good as it usually gets. Though, one day I assisted with a bedside chest tube insertion -- that was a bit more exciting! On a typical day, I may be taking care of six patients with the following complaints:

1. 73 year old with acute renal failure, diabetes, & cancer
2. 62 year old with syncope (one of the church drops)
3. 95 year old with bilateral pleural effusions, UTI, who is on aspiration precautions, &has a stage 1 on coccyx
4. 41 year old with chest pain
5. 68 year old with metastatic cancer
6. 64 year old with end stage renal disease due to uncontrolled diabetes, new onset UTI & pneumonia

Taking care of six patients with a wide variety of conditions can seem overwhelming. Truth be told, I've been known to groan as I read through kardexes. Organization is the key. On a good day, I have a routine that I follow. Coffee, kardexes, coffee, report, coffee, greet patients, review vital signs, review meds, last gulp of coffee, begin assessments & med passes. I have learned that a quick pop into each room after report makes my day a bit better. This gives me the opportunity to write my name on the whiteboard, let the patient know that I will be available shortly, and allows me to eyeball each person. That quick glance at the patient tells me a lot -- neuro status, respirations, safety -- all of which helps me prioritize the order in which I'll assess each person. It also tends to put the patient at ease -- someone is checking in and assuring him/her that they will be back.

Take a look at my list of six patients. Who would you have seen first? Who would you guess to be the most stable? The diagnosis doesn't always tell you what you need to know. I quickly learned that #1 was the most ill. This patient's condition had changed on night shift, and was worse when I got to him on day shift. Heart rate was tachycardic; he was diaphoretic, lethargic, edematous, had noisy respirations, and had crackles. When you see changes like this, routines go out the window. Put the patient on oxygen, check am labs, contact MD. End result? This patient received a dose of IV lasix and was transferred to ICU. An hour later, I was able to go back to my routine with my other patients.

The most stable patient was the one who passed out in church. Although this patient was stable, she wasn't a low maintenance type of gal. She wanted to go home -- NOW. Where was the doctor? Why weren't her home meds ordered? Why weren't her meds given first thing in the morning? What were her test results? In this instance, you have to be patient and diplomatic. If that doesn't work, beg & plead with the doctor to discharge the patient as soon as possible.

Right when you think you're getting your day back on track, something is bound to happen. Patient #4 may decide to have chest pain (nitro SL x 3, STAT EKG, repeat VS, call MD), and #5 has uncontrolled pain (lidoderm patches are wonderful). Throw an admission and a discharge into the mix, and you have one busy day. Oh, and don't forget to discuss patient needs with doctors as they round, phone calls to/from pharmacy due to med concerns, and critical labs to be addressed.

How do you manage a typical med/surg day?

1. You need a good brain. No, not the one inside your skull, but the paper kind that keeps you organized. Everyone has their own system. Ask around, try different ones out, and then use what works for you.

2. Never take shortcuts when it comes to medications. Look up unfamiliar meds, follow all precautions, and always check your 5 rights (three times, every single time). You really need to have a healthy fear of the harm you can cause.

3. Learn to always trust the nagging voice inside your head. If something doesn't look or feel right, it probably isn't right. That was certainly the case with my first patient of the day, and I have many more examples just like that.

4. Remember the Golden Rule. This applies to patients, aides, pharmacy, PT/OT, dietary, RT, secretaries, MDs, housekeeping, transport, and anyone else I failed to mention. Most interpersonal conflicts can be avoided by being kind and showing respect to all you encounter.

5. Ask questions!! Yes, there are stupid questions, but don't let that stop you. I've earned a lot of respect from people by being willing to admit that I don't know all of the answers. The more questions I ask, the more I learn.

6. Use critical thinking. When I was in nursing school, I hated some of the critical thinking exercises we had to complete. Now, I can't say enough how important it is to stop & think about all that you are doing. Do you really want to give heparin to a patient with critically low platelets? Do you really want to give that oral diabetic medication to the patient who's blood sugars have been low & hasn't been eating much? What about the patient with back pain? Would a lidoderm patch help more than the narcs? (yes -- I love patches...)

7. Have a sense of humor! Don't take yourself too seriously. If you can laugh on a crazy, busy day, you'll manage much better.

Again, I never expected to love med/surg nursing. I thought I'd give it a try because I was always told that it is the best place for a new nurse to start. After a couple years, I have to agree with that advice. Med/surg nursing exposes you to a variety of medical/surgical conditions, AND it enables you to hone your organizational skills. It really does teach you how to nurse on the fly.

Thank you so much, DreamingTree, for sharing with us! It definitely sounds like you get a wide variety of experiences in Med Surg.