Maybe you’re trying to figure out if you want to go to nursing school… maybe you’re in school and not sure of where you want to work… or maybe you’re an experienced nurse looking to change things up. Many have heard of med surg nursing, but are not sure what med surg nurses actually do during a typical shift.
Well, you’ve come to the right place! Let’s walk through a typical shift on my [cardiac] med-surg unit.
What Do Med Surg Nurses Do?
Starting your shift – report
Like many other areas of nursing, the med surg nurse will begin his or her shift in report. The off-going nurses share information with the oncoming nurses about their patients. The number of patients a med surg nurse nurse will care for during the shift will vary depending up the state and facility in which you work.
A good nurse to patient ratio on a med surg unit, in my personal experience at the bedside, is 4 patients to 1 nurse. With 4 patients, I can keep information about them straight easily, have enough time to see each one and not feel rushed through interactions to get my other patient’s medications and tasks addressed. I’ve seen ratios as high as 1 nurse to 7, 8, and 9 patients on med surg units, however. Therefore, if you’re looking to become a med surg nurse, make sure you ask about the nurse to patient ratios in the interview because they can vary widely.
Report typically lasts about 30 minutes, so around 5 minutes per patient plus some time to have a short huddle of the entire shift of nursing staff members, and some time to find each nurse to obtain report from.
Here is a video example of me giving report on a fictional med surg patient:
Generally speaking, the information discussed report on a med surg unit consists of the following:
- Name / MD’s / Code status / allergies
- Precautions (fall, seizure, infection prevention, bleeding, etc.)
- Chief complain / why they’re in the hospital and important things that have happened during the admission
- Pertinent history (it’ll take time to figure out what pertinent and not, don’t get hung up on this one. You’ll also figure out, with time, shorthand/abbreviations for history)
- Abnormal assessment findings from body systems (do not waste time going through normal information)
- If they’re on oxygen and how much via which delivery method and if that’s changed recently (nasal cannula, face mask, non-rebreather, etc.)
- Any tubes (feeding tubes, foley catheter, rectal tube, etc.)
- Intravenous access (IV, central line, port, etc.)
- IV fluids / drips / anything continuously infusing
- Activity level / how they go to the bathroom
- Pertinent / abnormal labs
- Questions to ask MD / questions for any other member of the health care team
- Any psychosocial / family + support system concerns
- Important meds (you can look up this stuff in the chart, but they may mention some meds)
- Any tests, procedures, transfers, etc. that need to occur during this shift
- General discharge plan / what are our goals this shift? (get out of bed 3 times, eat, pass swallow evaluation, transfer out of ICU, etc.)
As the oncoming nurse, you will be RECEIVING all of this information and need to be aware of it throughout your shift. At the end of the day, you will provide it to the night shift.
It’s a lot of information in a short amount of time. A good report sheet is really helpful as well because you will not memorize all of this information! Here’s a great resource of 33 free PDF’s of nursing brain sheets. (Yes, the one I use is in there!)
The beginning of the shift – right after report
Once I obtain a report on all of my patients, I need to collect my thoughts for a few minutes. Provided everyone is stable and no one needs anything urgently, I’ll find a computer and start looking up additional information in the chart. I look up any questions from the report about missing information (for example a lab value if a certain test has come back yet, if a scan scheduled later if physical therapy is ordered).
I also spend this time organizing my to-do list for the day.
This list includes:
- My documentation requirements
- Assessment, telemetry strip, education, care plan, IV and pain assessments
- Medication due times
- At this time I also am ensuring all medications are appropriate to give and if any need to be held
- Vital signs
- How often they’re ordered and their trends
- Their ordered parameters for vitals (keep their systolic less than 160 and use PRN meds to keep it below that)
- Blood sugar checks
- How often, if there is sliding scale or scheduled insulin, how they’re been running
- Follow-up labs based off a drip, continuous infusions, and weaning parameters – below are some examples
- PTT or Anti-Xa for a heparin drip
- Cardizem or Amiodarone drips, noting their heart rate, blood pressure, and cardiac rhythm
- Enteral feedings, noting the ordered goal rate, residuals, bolus vs. intermittent feedings
- TPN, noting its necessity, access point, and blood sugar monitoring
- Questions for the rounding provider(s) – below are some examples
- The patient is eating and drinking well, would you like to discontinue their IV fluids?
- The patient has 20 mEq potassium PO BID scheduled, but her K+ on her BMP this morning was 5.5, would you like to discontinue it?
- The patient has not had had cardiac events in 5 days, may we discontinue the order for cardiac monitoring?
- The patient does not seem to be tolerating their diet and I’m concerned about aspiration. Can we order a speech evaluation?
- The patient has refused their Nicoderm patch for the last 5 days, can we discontinue the order?
- The patient’s IV antibiotics have been completed and appear to have decent options for peripheral IV access. Would you like to remove the central line?
This takes around 10-15 minutes to get everything together. I make sure my brains are well organized with information and to-do checklist for each patient, I have what I need in my pockets (alcohol swabs, saline flushes, Sharpie, pen, brains, unit phone), and a full bottle of water, and get ready to begin my day!
(If you want to see all of my recommended nurse gear from scrubs, to bags, to socks, to water bottles, check out my nurse gear master post.)
Seeing my patients
After I’m all geared up, I decide which patient I will see first. What influences this decision depends on if anyone has a time-sensitive medication (like insulin) or needs to get off the unit ASAP (for something like dialysis or some other off-unit procedure). If someone is leaving the unit, I’ve got to visit them first.
Basically, I need to see every single patient and complete a nursing assessment on them. This consists of a basic assessment of each body system, focusing on areas of concern if needed. This only takes a minute or two, depending on what’s going on with the patient. I’ll start with asking basic orientation questions, listen to heart/lung/bowel sounds, look at skin, feel pulses, look incisions/wounds, ask about pain, elimination, ambulation, and a few more things.
After I’ve completed my assessment, I then administer their scheduled medications and see if any as needed (or PRN) medications are needed. These meds can be things like pain meds, nausea meds, stool softeners, and more.
I then see if the patient needs anything specific from me, and discuss the plan of care/plan for the day with them and their loved one(s) briefly.
“So, I’d like to go over the plan for the day with you. Currently, the plan for today will be to not eat or drink anything until the cardiologist comes by and takes a look at you. He or she will determine if we need to go for that ultrasound called a transesophageal echocardiogram later today to get a better look at your heart. Your labs should be back for them to look at, and they will look at that ECG that was just taken as well as the heart monitor that was on overnight. I will give you your normal medications with sips of water this morning, but that’s about all you can have to drink until we hear more. I know that was a lot of information. What questions do you have for me?”
Assessment, medications, education, repeat
I basically do this routine with my entire patient load. If I find something alarming or concerning in my assessment, labs, monitoring, or in talking to the patient, I alert the physician or the advanced practice provider (abbreviated as an APP, meaning a nurse practitioner or physician assistant).
Pro-tip: don’t call nurse practitioners or physician assistants midlevels or physician extenders. Some don’t care, but many really don’t like that. Here’s an article with a little more information about why.
As the nurse at the bedside, I’m the one who’s responsible for monitoring the patient all day. While the provider (physician, physician assistant, nurse practitioner) rounds once a day for a few minutes, I’m there the rest of the time. They are relying on me and my clinical judgment to communicate any concerns promptly.
And I love it.
As you can imagine, I have to be somewhat speedy when seeing all of my patients to make sure everything is completed on time (4 people have 9:00 am medications due and I am one person who is responsible for administering them all before 10:00 am). Not only do I have to assess, give meds, and education, I have to document it all.
I have a love-hate relationship with documentation. I loathe documenting because it takes up so much time and is frustrating. However, when I’m trying to figure out what’s going on with a patient, I rely on documentation to do so. If the previous nurse didn’t chart the meds, blood pressures, or assessment findings, I can’t compare it with what I’ve done or my current issues and concerns.
Sadly, documentation is a necessary evil.
Furthering the care plan – working towards discharge
In addition to rocking out awesome assessments and safely administering medications, med surg nurses are also focused on furthering the patient’s care plan and getting them safely discharged.
During my time in intensive care, the discharge was not a big part of the report or my hour-to-hour tasks. While we took note of potential discharge needs, it was not a focal point because their needs were still pretty up in the air due to current circumstances. Med surg nursing is different – we are pretty focused on discharge about when and how we are going to do so safely.
Oh, and don’t forget…
Discharge can be smooth as silk or pretty tricky. Some patients have great support systems, some don’t, some have significant financial concerns, transportation issues, health literacy issues, and more. There can be quite a few things to get into place when trying to get a patient home. Med surg nurses work closely with case management and social work to help facilitate discharge to help address concerns or get patients to another facility if needed.
Med surg nurses are also working even closer with physical, occupational, and speech therapy because their assessment recommendations are required for insurance purposes to get things covered (like nursing home stays, rehab, home health, medical requirement) by insurance.
Rounding – the entire team
The typical routine during the day shift is that the attending and consulting physicians and their support staff round on their patients.
What are rounds? When a physician and/or advanced practice provider sees, assess, write orders, and document a progress note on their patients
This means that most patients are being seen by their provider during the day shift. This is typically when most orders changes occur. Patients may be discharged, medication changes, activity order changes, procedures, new dressing changes, removing tubes or lines, and so forth.
This is an important time because you know the providers will be rounding, so you can address non-urgent needs at this time, provided they touch base with. Because you have 4+ patients, it’s not a guarantee that you’ll be in the patient’s room when the providers round. You know you’re working with an awesome and efficient provider when they take the time to call/find you during rounds to update you and see if you have any needs.
If you work in a teaching hospital, you may also work with residents. They may “pre-round” early in the morning to see their patients and get themselves ready for rounds with their attending (the physician they report to during their training). They may come by and ask you questions and touch base at this time, and then again later with the rest of the team.
Any other consulted member of the health care team may also round. This means physical therapy, occupational therapy, speech therapy, case management, pharmacy, social work, dietitians, chaplains, and so forth.
You may have to participate in interdisciplinary rounds as well. This is when the entire health care team gets together and rounds on the patients in the unit. From the med surg perspective, rounds are typically more discharge-focused than in the critical care setting. This means that you have to manage your time appropriately to be available for these rounds also.
As you can imagine, it’s a lot to coordinate for one patient – let alone 5 or more. I have to carry a phone with me throughout the shift so people can speak to me as needed without searching the entire unit for me. I feel like it rings every 5 minutes. If I have 5 patients and they all have a medical team, PT, OT, and case management, that’s at minimal 20 calls right there.
But let’s be realistic – it ends up being much more than that!
Admissions, transfers, discharges, oh my!
Another important aspect of the med surg level of care is discharge planning.
Things med surg nurses do in regards to discharges:
- Work closely with case management (CM), social work (SW), therapy services, etc., to ensure the patient is safe to go home
- Provide detailed discharge instructions and teaching
- Ensure patient can obtain discharge prescriptions
- Facilitate transportation (typically with CM/SW)
- Facilitate obtaining getting any financial assistance (typically with CM/SW)
- Ensure all needed discharge orders are placed
- Ensuring all core measures / required documentation / required education has occurred
- Facilitate transfers to other facilities like nursing homes, skilled nursing facilities, rehab (again, typically with CM/SW)
- Teach the patient about wound care, taking meds, eating, bathing/showering, follow-up appointments and lab draws, contact information
- Oh, and documenting ALL OF THAT.
Once you get a patient out the door, typically there’s another one waiting to come to your unit. There is quite a bit of turnover on a med surg unit. As patients are discharged, others fill their place. While I may start a shift with 4-5 patients, I may discharge 2 and get different 2 back.
Admissions have their own set of documentation requirements, assessments, medications, and orders. Transfers (typically a patient who was in intensive care who no longer needs close monitoring is “downgraded” to a med surg unit) also occur, but typically have less paperwork because it’s all been taken care of in critical care or another unit.
It is a safe assumption that if the unit you’re working on a unit with a 4:1 or 5:1 nurse to patient ratio, that you will most likely always have 4-5 patients. Nursing units have to adjust their staff based on the number of patients on the unit. So, you won’t have days where you only have 1-2 patients because if that were the case, they would either send a nurse home and give the other nurses the additional patients or send that nurse to another unit who needs another nurse.
I wish we always had the same number of nurses every shift so nurses weren’t always constantly busy, thus enabling us to do things like check our email, complete education and training, and simply be more present… however, that’s not the case.
Because you’ll most likely always have as many patients as you’re allowed to take, it is crucial to learn how to manage your time, delegate to your assistive personnel (page 85), and prioritize your efforts (page 99).
Towards the end of the shift (a mere 11 hours later…) you start to consider concerns for night shift (or the next shift) and make sure all routine needs for the physician have been addressed.
Pro-tip: it is not cool to call a physician or APP at midnight for a non-urgent need that could have been addressed during the day with the attending physician. They will almost always tell you to wait until the next day when the patient’s normal physician is on because it is much more appropriately addressed by them. Nursing school teaches you to notify and clarify about many things with the physician, but doesn’t necessarily go over when. I dive deep into this topic in my book.
The end of the shift includes ensuring all tasks and required documentation were completed. This includes care plan documentation, education, and incident reports if they were necessary. Nurses must document how they educated their patients and how they furthered (or attempted to further) the patient’s plan of care safely towards discharge.
You also begin getting ready for the report. Now that your shift is coming to a close you will provide a short, yet detailed, report to the oncoming nurses caring for your patients. Nursing care is a continuous process. Some days you’ll have a crazy shift and won’t have finished that admission navigator, discontinued that non-essential order, remembered to ask that one question, or perfectly tucked and fluffed all of your patients. Some days, you’ll be thankful to have everyone’s meds passed and bare minimum documentation completed… while other days, you’ll be early or on time with everything and have all of your patients ready to go for the next shift.
Each shift is different, patients are dynamic, and things change in an instant. Ah, nurse life.
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Alright guys, my work here [for the last 12 hours] is done…
- Anatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey – written by Kati Kleber, BSN RN CCRN
- What Does an ICU Nurse Do – FreshRN Blog