Introduction to Medical-Surgical Nursing – McGraw-Hill

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                        Introduction to

 In this chapter you will review:
 O The function and purpose of the medical-surgical unit.
 O The scope and role of the medical-surgical nurse.
 O The impact of culture on the provision of care in the medical-surgical setting.
 O Patient safety in the medical-surgical setting.
 O Utilization of the nursing process in the medical-surgical setting.
 O Documentation of care in the medical-surgical setting.

2 MARLENE HURST  Hurst Reviews: Medical-Surgical Nursing Review

                                        THE MEDICAL-SURGICAL UNIT
                                        Hospitals organize patients in order to create the optimal healing envi-
                                        ronment. The medical-surgical unit has often been described as a "catch-
                                        all" for different types of patients. This is not to be confused with
                                        patients who are uncomplicated or do not require specialized care.
                                        Patients who are hospitalized in today's health care environment are
                                        most likely experiencing a serious acute illness or the exacerbation of a
                                        chronic illness. This patient mix includes surgical patients, cardiac
                                        patients, cancer patients, renal patients, and everything else that doesn't
Hospital admissions are necessary
                                        fit into one of the specialized categories.
when a sick person needs a nurse
                                            The medical-surgical unit is a conglomeration of all kinds of nonpreg-
around the clock.
                                        nant adults having all sorts of health problems; therefore, nurses on such
                                        a unit must be versatile and on their toes at all times! Emergency
                                        Department nurses (who expect emergencies) are well equipped to deal
                                        with emergency situations because they deal with life-and-death emer-
                                        gencies on a daily basis, and they are always looking for complications
                                        secondary to trauma. Nurses on a medical-surgical unit must be careful
Specialized units (pediatrics, inten-   not to develop a "ho-hum" attitude toward routine nursing care, as their
sive care, obstetrics) have sick
                                        patients can experience rapid changes in condition and quickly become
patients with more predictable
                                        unstable even though they were admitted for the predictable kinds of
needs, but the nurse on a medical-
surgical unit must be prepared to
                                        conditions commonly seen on a medical-surgical unit.
take care of adult patients across          The largest percentage of medical-surgical nurses are employed by
the life span who have all kinds of     acute care facilities; however, there are opportunities for provision of care
acute and chronic health issues,        by medical-surgical nurses in other settings. These settings include but
many of which can deteriorate into      are not limited to clinics, outpatient surgery centers, physician offices,
emergency situations.                   long-term care facilities. In other words, patients require medical-surgi-
                                        cal care across a wide expanse of the health care spectrum.

                                        The nursing process
                                        The nursing process is how we do what we do! The nurse has a scientific
                                        knowledge base from all nursing research and other disciplines (anatomy
                                        and physiology, psychology, nutrition, chemistry, etc.), and uses the
                                        nursing process to provide evidence-based nursing care. A sound
                                        understanding of the nursing process is mandatory for all nurses in
                                        any practice area.
                                          The nursing process is the organizing framework for all nursing care.
                                        The phases of the nursing process are:
                                        O Assessment
                                        O Diagnosis
                                        O Planning
                                        O Implementation
                                        O Evaluation

                                        Nursing assessment is the initial and most important phase of the nurs-
                                        ing process. If you miss something, how can the best nursing diagnosis
                                                        Chapter 1  Introduction to Medical-Surgical Nursing 3

be assigned? It can't! The RN always has to complete the admission
assessment, because this is the time when the patient is assessed from
head to toe, just to make sure that something important is not being
missed.                                                                         The admission physical assessment
                                                                                and nursing history are only per-
CASE IN POINT What if the patient is admitted with an ingrown toenail           formed by the registered nurse!
and all that we focused on was the toe? If I missed night sweats, remit-
tent fever, and a chronic cough, then I could possibly spread TB all over
the surgical unit! The admission nursing assessment and history is too
important to delegate to non-nurses! Does this mean that the CNA can-
not get your admission vital signs and weigh my patient? Certified nurse        Objective data=can be observed
aides are supposed to be able to correctly perform these tasks; however,        The big "O"= Observed
since drug dosing is based on weight and comparisons of vital signs refer       Anything that can be observed
back to baseline, the RN obtains these initial data. Does this mean that        (seen by the nurse, such as moist
the RN has to go through every pill bottle in a 10-pound grocery sack of        rales in a lung, lesions on the
medications to write down every dosage and schedule, plus when it was           body, vital signs, or lab tests) are
taken last? No, it does not. The LPN is a licensed staff member who is          always objective data.
perfectly capable of filling out the medication reconciliation record! But
the RN is required to sign the admission form verifying all data. And the
RN oversees all aspects of care; but we will discuss this more with princi-
ples of management and delegation.
                                                                                Anything that the nurse cannot
                                                                                detect independently is subjective
                                                                                data, because the patient will have
 Subjective Versus Objective Data                                               to tell you about the complaint. The
                                                                                nurse can see the patient grimacing
 Some aspects of physical assessment can be seen by the nurse, and other        and limping with each step (objec-
 aspects of physical assessment must be based on what the patient tells you.    tive data because the nurse can see
                                                                                this), but the nurse must share these
                                                                                observations with the patient and
                                                                                ask if pain is present (subjective
                                                                                feeling experienced by the patient).
Nursing diagnosis
The second phase of the nursing process requires what your nursing
instructors call "critical thinking."
O First, you assess your patient and differentiate normal versus abnormal
  findings.                                                                     Subjective = Has to be stated
O Then, determine what is normal for your patient depending on the              (said) by the patient
  history and disease process.                                                  The big "S" = Stated (by the patient)
O Next, analyze data from your complete nursing assessment, and inter-
  pret what the data mean.
O Once you determine the patient's problem, you're ready to go to the
  list of patient problems that NANDA (North American Nursing
  Diagnosis Association) put together for us, and pick out the appropri-        When performing patient assessments,
  ate nursing diagnosis! Now we are ready to roll!                              the first step is to compare everything
                                                                                you see with normal physical assess-
                                                                                ment findings. Then, based on patient
                                                                                history, consider what is normal for
If you miss the boat on the nursing diagnosis, your planning isn't worth        that particular patient.
a "toot!" That's why your data (objective and subjective) needs to be
4 MARLENE HURST  Hurst Reviews: Medical-Surgical Nursing Review

                                       complete and verified with the patient. Planning always starts with decid-
                                       ing which patient problems need attention first!
                                         In addition to setting priorities, the planning phase of the nursing pro-
Now you see why "thinking" is          cess is also a time for setting realistic, attainable patient goals that pro-
critical! All those notes you have     vide the direction for selecting interventions to accomplish the desired
written down, the patient lab work     patient outcomes.
and X-rays, plus the subjective data
obtained from the patient are all      Implementation
pieces of the puzzle that you put
                                       Now we are ready to carry out the planned actions (nursing interven-
together with the processes of
analysis and interpretation to come
                                       tions) during this caregiving phase of the nursing process.
to a conclusion about the patient's    O These interventions can be independent, interdependent, or dependent
problem.                                 actions.
                                       O A large portion of nursing interventions come from the nursing
                                         domain: things that nurses have been taught to do that are based on
                                         scientific, outcome-based, nursing knowledge.
                                         As nurses we cannot do everything independently, so we collaborate
                                       with other members of the health care team to carry out interdependent
Sometimes you will find that you       nursing interventions. For example, you know (independently) your
need additional data in order to       patient who has an endotracheal (ET) tube needs mouth care and a lem-
come to a conclusion about your
                                       on-glycerin swab will not suffice. Here's what to do:
patient's problem. That's when you
go back to the drawing board!          O Collaborate with the physician for a peroxide-based oral solution.
                                       O Wait for the respiratory therapist (RT) to change the mouth piece/bite
                                         block and the Velcro strap holding the ET tube.
                                       O Enlist assistance of the RT to secure and stabilize the endotracheal
                                       O Clean, suction, and rinse the patient's mouth during a time when
The ABC method is always good to
                                         everything is out of the mouth and you can see what you are doing!
use when setting priorities, but
don't pick airway as the priority if   O We all work together (interdependently); because none of us want the
your patient does not have an air-       patient to develop a lung infection from a yucky, bacteria-filled
way problem!                             mouth!
O A = airway                              We aren't finished with the implementation phase until we do the
O B = breathing                        paperwork! We have to document the patient response (during and after
O C = circulation                      the intervention) and share this information with other health care team
                                          Charting (documentation) may be done using pen-and-paper; nurse's
                                       notes or flow sheets, or may be computerized charting, done at the bed-
                                       side. Regardless of how you chart, institutional guidelines for use of
                                       accepted abbreviations must be followed to the letter! Because so many
If your diabetic patient has an air-   errors are preventable, abbreviations are changing to protect the patient.
way problem, but you decide to do
foot care first, nobody except the
mortician will see what a good job
you did because they don't usually     During the evaluation phase of the nursing process, you have to deter-
open the lower half of the casket      mine whether or not the plan is working. You ask yourself:
for viewing.                           O Have goals been met?
                                       O Are the short-term goals being met with progress toward long-term
                                                    Chapter 1  Introduction to Medical-Surgical Nursing 5

O Is this plan of care working to accomplish the patient's highest possi-
  ble level of wellness?
  The nurse has to reassess whether the plan of care is accomplishing the
expected outcomes! Notice that we have to assess again!                      Thorough assessments are
O We are always assessing and reassessing the patient's response to every-   required, especially in emergen-
  thing!                                                                     cies, taking all relevant data into
O And we are always evaluating and re-evaluating everything too!
  The evaluation phase is never ending.
O Some patient issues resolve and are no longer priority.
O Other problems change or new problems present themselves!
   That's why nursing is so FUN! Nothing is ever the same (static)!          Independent nursing
Patient needs and related nursing care are constantly changing (dynamic)     intervention=based on nursing
from minute to minute and day to day.                                        knowledge
   SBAR form of communicating the patient status in terms of recovery,
risk reduction, or rehab concerns. This format originated with com-
manders in the armed forces, and was used when one commander
"handed-off " to another:
S = Situation: Describe the current problem.
                                                                             Dependent nursing intervention=
B = Background: Give the doctor a rundown on the patient (admission          based on a specific physician order
  diagnosis and vital signs, treatments, previous lab results, or whatever
  is relevant).
A = Assessment: Share conclusions (based on assessment) about the
  patient's problem.
R = Recommendation: Offer a statement of what you believe would be
  helpful to remedy the patient's problem.                                   Not all nurses are as smart as you
                                                                             are! Abbreviations used improperly
Therapeutic communication                                                    have been identified as a major
                                                                             source of medical errors. For exam-
Therapeutic communication is sending, receiving, and interpreting infor-     ple, od (right eye) and os (left
mation necessary for all interactions with patients, families, and health    eye) may not be acceptable
care personnel. Communication is verbal, which includes the written and      abbreviations, because one "not so
spoken word, as well as nonverbal, which includes tone, gestures, body       smart" nurse squirted eye drops
language, and physical presence when silence is used. All therapeutic        into a patient's mouth (per os)
communication is "for good" and is goal oriented rather than just            rather than his left eye! This is why
"shooting the breeze" (talking to be talking) about trivia, or making        certain things need to be written
social conversation.                                                         out clearly!
O Beginning with the birth cry, communication is a basic human
  need: the ability to make needs known, to understand, and
O Therapeutic communication is powered by the need to know, under-
  stand, and validate.                                                       The Joint Commission which pro-
                                                                             vides accreditation to health care
O Therapeutic communication facilitates acceptance of health care
                                                                             facilities released a list of "Do Not
                                                                             Use" abbreviations in 2001 in an
O Information must be elicited from patients and family members in           effort to reduce medical errors and
  order to understand and prioritize needs for planning care.                increase patient safety.
O Continuation of care demands effective goal-directed communication.
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