med surg

Jake reaches in his pocket and pulls out a crumpled scrap of paper scribbled with “101.2 temp Room 2112” and hands it to Ashley, the registered nurse.  Ashley nods and says nothing but is inwardly alarmed because she knows a temperature plus a source of infection can be a sign of deadly sepsis.  This patient has a deep red streak running up his painfully swollen forearm from an untreated cat scratch. She grabs a computer to check 2112’s labs and antibiotics, but out of the corner of her eye spots the confused elderly man in 2118 pulling out his IV. She sprints to stop him but is too late. He was in the middle of a blood transfusion and now there is blood everywhere.

Simultaneously a surgery nurse in green is pushing a gurney towards  Room 2114. The patient is Mrs. Brown, a post-op knee replacement patient who is groggy and moaning in pain. There’s an emesis basin on the pillow by her head. A sign she’s nauseated.

Mrs. Brown will immediately need a patient controlled analgesia (PCA) machine that allows her to self-administer morphine injections to control her knee pain. PCA machines are complex to program and require full and mindful attention during set-up to avoid narcotic overdose. Ashley will have to closely monitor her patient for signs of respiratory depression while on the PCA. Ashley makes a mental note to make sure to get Mrs. Brown up before the end of her shift to ambulate for early mobility.

The daughter of the patient in Room 2116 is standing in the hall, coffee cup in hand, glaring at Ashley because her mother asked for more coffee earlier. Ashley will have to make a fresh pot of coffee herself in the cramped food room. As soon as she’s able. Stressed, Ashley feels guilty and avoids eye contact. Ashley knows the family doesn’t understand that she really wants to bring their mom a nice fresh steaming cup of coffee.

Ashley feels the phone in her scrubs pocket vibrate. It’s the Lab. “Your patient in 2120 has a critically low potassium level.” Low potassium levels cause erratic and dangerous heart beats. While calling the doctor, Ashley rushes to Room 2120 to apply a telemetry monitor to monitor her patient’s heart rhythm, essential with a low potassium. It’s an isolation room so first she must laboriously gown, mask and glove before entering the room. Stepping in the room, Ashley realizes her patient has soiled herself.  The patient is a 74-year-old woman, weak, and embarrassed. Ashley senses her discomfort and expends energy trying to make her comfortable by calmly making small talk, and trying not to appear rushed.

Ashley has only  five patients but even with five patients, things can spin out of control. Luckily, Ashley is in California, where staffing levels are mandated and Ashley cannot be assigned more than five patients on a medical surgical nursing unit. In most states, there are no set ratios.

—  The Real Story Behind Nursing Ratios - (Actually my life every day on trauma. Although add in more call lights going off, pt’s trying to fall out of bed and my phone going off every 5 seconds.)
Increased Intracranial Pressure

(>20 mm Hg) Due to a rigid and fixed skull, there is no room for any additional fluid, blood, or lesions. Additional matter without an expansion of volume, especially, creates increased pressure. Increased intracranial pressure is very serious and could lead to brain herniation and subsequent death.


  • Brain tumors
  • CNS infections
  • Cerebral edema
  • Intracranial bleeding
  • Excess CSF


  • Changes in level of consciousness (LOC) ***often the first indication***

Glasgow Coma Scale measures LOC via eye, motor, and verbal responses to stimulus from the environment. It scores from 3-15 w/ 8 being the “magic number” - think magic 8 ball. If you shake it up, or stimulate it, and a number < 8 appears a severe coma is present. 9-12 represents a moderate coma. 13-14 represents a mild coma.

  • Blurred vision
  • Coma
  • Decerebrate posture (extension of arms indicative of brain stem involvement)
  • Diplopia
  • Doll’s eye phenomena
  • Headache
  • Projectile vomiting
  • Behavior changes
  • Seizures
  • Cushing’s reflex (as manifested by Cushing’s triad):  increased BP w/ widening PP (peripheral resistance increased to shunt blood towards the oxygen-needy brain), decreased pulse rate (in a vagal-induced response to rising BP), decreased/irregular (Cheyne Stokes) respirations

Indicative of impending herniation - emergent medical response necessary.

Treatment of ICP

  • Keep HOB elevated at 30 degrees
  • Keep patient well hydrated
  • Frequent neuro-checks needed
  • Strict I&O
  • Anticonvulsants for seizure prevention (phenytoin)
  • Mannitol (osmotic diuretic used to reduce cerebral edema)
  • Loop diuretics
  • Avoid aspirin, narcotics, or meds that depress respirations (as they are already at risk for being low)
  • Hyperventilate patient (blow off CO2 [hypocapnia]) to decrease cerebral blood flow (cerebral vasoconstriction in response to low CO2 levels)
  • Decrease environmental stimuli
  • initiate seizure and safety precautions (padded side rails up, call light w/in reach)
Watch on

This is a very inspiring video for all those struggling in nursing school !!


Today is the start of something AMAZING. I had a great day first day of immersion on the med surg unit at Ronald Reagan. My preceptor is so sweet and a great teacher! The other staff on the floor is incredibly nice and funny AND today spirtual care came by and brought us diddy riese cookies and tea! It was called tea for the soul haha. 

I’m gonna have to work nights soon too but I’m ready for the challenge. Also, two other past immersion students got hired onto that unit. I hope and pray that could be me one day!! I think this will be a great experience and I might already have an idea on what to do for my big capstone project! :) 

When I hear high school students complaining about how hard their homework is

“I still haven’t written that 4 page paper on Lord of the Flies. I’m going to be up all night, oh my gosh I’m so stressed out you guys.”

While I’m sitting there working on a 32 page care plan.

You just shut your mouth.


Sooo I finally started nursing Clinicals this semester and they are going great! first half of the semester I had Mental Health and right now I’m currently in Med/Surg. It is no easy work but I love it! There’s something about helping and working with patients that just makes me happy and proud. Sure when I get home I’m completely exhausted (even though it’s only once a week), but I’m starting to get used to it and learning a LOT. Soon I will be able to apply to be a CNA and hopefully start working in some kind of hospital setting to get gain more experience =)