Currently on orientation at a level 1 trauma ER,help!

nycRN3 · Dec 11, 2017

I don't know if this will help but this something that carried over from my FF/EMT, we always did scenario based training, so for almost my entire career I have conducted scenario training in my head-So I imagine I have a patient who codes, in my head I visualize each step of what I'm supposed to do, for severe bleeding same thing, for resp. arrest or depression same thing. I study the protocols and what my role is then I visualize in my head what I need to do, including starting IV's, watching for sx to change etc. I can say its made a lot of my reactions become almost automatic.
So start with something like a CHF patient who ate a bag of chips...imagine the symptoms/signs they'll have. They're heading to pulmonary edema so you make sure the HOB is up high, you apply oxygen, you listen to lungs, are there rales in all lobes or just the bases?( if the rales are getting high you want an intubation kit handy) you start an IV, you think about what meds might be needed, lasix, morphine, maybe nitro, EKG, etc. The above is not inclusive of everything you might do or need (Its been quite a while since I had a full blown chf/pulm. edema pt) but what I'm trying to say is if you visualize all the steps and equipment you might use/need, eventually it will become reflex. I use to visualize "practice" on my ride into work. This doesn't replace real training and orientation but if definitely helped me. Good Luck!

I've done something slightly like this and it does help a lot. I'm going to visualize the whole patient and interventions next time though. Such a great tip!

nycRN3 · Dec 11, 2017

Okay after allnurses did something weird with my response I am back to state my pointers.

Here are some tips that helped me transition from a mother/baby nurse to an ED nurse:

Know where your supplies are. Nothing is more annoying and time consuming then not knowing where to find something when you need it. It's even more frustrating when you're in the middle of a code and someone points at you and says, "Hey can you pass me a XYZ."
Learn how to do assessments . . . FOCUS ASSESSMENTS. I know a lot of floor nurses may get upset that I can not give them a full head-to-toe assessment but that is not what the ED is for.
Know your ABC's.In the ED everyone thinks that they are a priority, and if you try to get the pillow for every patient who wants one meanwhile in room 3 your patient is still wheezing waiting for their duo nebs. Not a good look. Sure your patient is having an asthma exacerbation, but HCAHPS should improve because you got three patient's a pillow in record time! (Obviously I am being sarcastic, lol)
Anticipate pt's needs and MD/PA/NP orders. Almost all ED patients are hungry and mid triage they will ask you the most important question, "When can I get a sandwich?" I pretty much answer the question before they can ask, "Hey since you're coming in with abdominal pain I recommend you not eat anything until your labs and imaging results come back."

Women under 55 get a urine cup from me immediately for urine pregnancy test. Before any medication orders or imaging is placed that requires a negative pregnancy test. Especially since people like to act like their kidneys no longer work when you ask for a urine sample. I always hear "I just went two hours ago."

If the doctor plans on intubating a patient I'll say, "Hey do you need a glide-o-scope? Want a bougie nearby? Lets get an OG tube also. Do you want this patient to be sedated with Propofol?"
Consolidate care. I know that I said finding supplies is time consuming but so is not bundling care. I get as much done for a patient at once. focus assessment, gown, monitor (if required), labs/IV, medication, documentation. Therefore I only need to go back to check back on my paient (based on acuity), update them, or if they call for me.
TEAM WORK! Pretty self explanatory. You're going to spend so much time with your coworkers. They are your work family. Even the ones you don't really vibe well with. I even help nurses who don't help people. Don't be the nurse who doesn't help people because there WILL come a time when you need help. Especially because the help you give is not really for the nurse it's for the patient. It's making sure their needs are addressed, making sure the lab test are sent out in a timely matter.
Policies.You may think you know a policy, but do you REALLY know a policy? It's happened to me a few times where policies have changed on me a few times. Your coworkers may not be aware. Luckily for us we a clinical nurse specialist for the ED who goes around and updates us. I like to save some of the major ones to my favorites.
CODES. For codes I like to increase my responsibilities. At first I would just watch. Then I moved into being the one to insert the IV line, then I'd get the meds, then I'd be the scribe. I am still improving myself and always watching the nurses who inspire me and learning what I could have done better.

September 6, 2017 made it one year since I have been in the ED and I have learned so much I am truly proud of myself. I am also humbled by how much more I have to learn. But it is a process, and don't be ashamed to say with confidence, "Hey, I am unfamiliar with this. Can you help me this time, so that I can know what to do?" (But yeah, also be careful of which nurse you're asking for help because some nurses follow their own policies.)

Best of luck!

Editorial Team / Moderator · Dec 11, 2017

Okay after allnurses did something weird with my response I am back to state my pointers.

I am glad you did, because this is great advice! :)

lainaa · Dec 11, 2017

Okay after allnurses did something weird with my response I am back to state my pointers.
Here are some tips that helped me transition from a mother/baby nurse to an ED nurse:
Know where your supplies are. Nothing is more annoying and time consuming then not knowing where to find something when you need it. It's even more frustrating when you're in the middle of a code and someone points at you and says, "Hey can you pass me a XYZ."
Learn how to do assessments . . . FOCUS ASSESSMENTS. I know a lot of floor nurses may get upset that I can not give them a full head-to-toe assessment but that is not what the ED is for.
Know your ABC's.In the ED everyone thinks that they are a priority, and if you try to get the pillow for every patient who wants one meanwhile in room 3 your patient is still wheezing waiting for their duo nebs. Not a good look. Sure your patient is having an asthma exacerbation, but HCAHPS should improve because you got three patient's a pillow in record time! (Obviously I am being sarcastic, lol)
Anticipate pt's needs and MD/PA/NP orders. Almost all ED patients are hungry and mid triage they will ask you the most important question, "When can I get a sandwich?" I pretty much answer the question before they can ask, "Hey since you're coming in with abdominal pain I recommend you not eat anything until your labs and imaging results come back."

Women under 55 get a urine cup from me immediately for urine pregnancy test. Before any medication orders or imaging is placed that requires a negative pregnancy test. Especially since people like to act like their kidneys no longer work when you ask for a urine sample. I always hear "I just went two hours ago."

If the doctor plans on intubating a patient I'll say, "Hey do you need a glide-o-scope? Want a bougie nearby? Lets get an OG tube also. Do you want this patient to be sedated with Propofol?"
Consolidate care. I know that I said finding supplies is time consuming but so is not bundling care. I get as much done for a patient at once. focus assessment, gown, monitor (if required), labs/IV, medication, documentation. Therefore I only need to go back to check back on my paient (based on acuity), update them, or if they call for me.
TEAM WORK! Pretty self explanatory. You're going to spend so much time with your coworkers. They are your work family. Even the ones you don't really vibe well with. I even help nurses who don't help people. Don't be the nurse who doesn't help people because there WILL come a time when you need help. Especially because the help you give is not really for the nurse it's for the patient. It's making sure their needs are addressed, making sure the lab test are sent out in a timely matter.
Policies.You may think you know a policy, but do you REALLY know a policy? It's happened to me a few times where policies have changed on me a few times. Your coworkers may not be aware. Luckily for us we a clinical nurse specialist for the ED who goes around and updates us. I like to save some of the major ones to my favorites.
CODES. For codes I like to increase my responsibilities. At first I would just watch. Then I moved into being the one to insert the IV line, then I'd get the meds, then I'd be the scribe. I am still improving myself and always watching the nurses who inspire me and learning what I could have done better.
September 6, 2017 made it one year since I have been in the ED and I have learned so much I am truly proud of myself. I am also humbled by how much more I have to learn. But it is a process, and don't be ashamed to say with confidence, "Hey, I am unfamiliar with this. Can you help me this time, so that I can know what to do?" (But yeah, also be careful of which nurse you're asking for help because some nurses follow their own policies.)
Best of luck!

I APPRECIATE YOUR RESPONSE SO MUCH! I am a visual learner so i HAVE to write thigs down and observe before I can do a skill/procedure. The ED has been so intimidating lately but I am determined to get through it even though I feel like this is hazing lol.I definitely take into account your advice ASAP!

DeeAngel · Dec 11, 2017

Consider studying for an hour or two a day for the first year if this is at all possible. It will really help to bring you up to speed and to feel more comfortable. For what its worth the first year is terrifying no matter what you do. There are all sorts of reference apps for your phone, is this something that might help you?

I promise you, it gets better and easier and the more you study the faster you will progress to that point. Take a deep breath......you are going to be OK.

lainaa · Dec 11, 2017

Consider studying for an hour or two a day for the first year if this is at all possible. It will really help to bring you up to speed and to feel more comfortable. For what its worth the first year is terrifying no matter what you do. There are all sorts of reference apps for your phone, is this something that might help you?
I promise you, it gets better and easier and the more you study the faster you will progress to that point. Take a deep breath......you are going to be OK.

Thank you for the encouragement!this definitely eases my nerves seeing how many people have responded to my concerns here!I feel less alone and in less of a panic.I currently for the past month now have been using my days off to study study study!So far its been helpful!

gemmi999 · Dec 12, 2017

Biggest, BIGGEST, thing I can do to set myself up for success is bundle care! I'd rather round on my current patient's, anticipate their needs, and then spend 15 - 30 minutes with my new patient getting hx, monitor, IV, labs, urine specimen (straight cath if needed, etc), answering questions and documenting. Then I just watch and wait for orders and reassess my patient's.

The other thing that stuck with my from my first preceptor is that if vitals are q2, and it's been an hour and you have some free time, do the darn vitals because you don't know what you're going to get next and you don't want to be the one that hasn't updated their pt's vital signs in three or four hours because a resp. arrest septic patient came in that required your focus for a while as you stabilized them. Basically--don't wait. If you can do it now, do it now vs waiting.

JKL33 · Dec 12, 2017

Keep your patients on the monitor and learn how to set up your monitors to cycle BPs at appropriate intervals so you aren't caught without vitals.

Much good advice in this thread. Personally, this is one of my favorite ^ useful practices. Not only don't you get caught without vitals, but you're able to quickly glance at them whenever you want during the course of care. Some coworkers apparently don't agree w/ me, but I usually have pt's who are "solid 3s" on VS monitor (not necessarily cardiac monitors, but sometimes...). It just helps to not "lose track" of them; I don't know how else to say it. And every once in awhile being able to glance at or trend those vitals uncovers an evolving problem or signals a change in condition. From a real-world POV, every patient that has a pulse-oximeter in place with a good waveform is one patient who I know is still in the bed (generally-speaking), still breathing, still status quo.

JoeRN8 · Dec 13, 2017

Thanks for this advice! In a similar situation and sometimes it feels so hard to focus on what I need to do. Some days I feel so ahead of the game and can actually finally take the time to ask everyone if they need help (Tried when I first started so I could show I'm a team player, and they mostly said to work on my stuff more because they knew I was new and didn't want to see me get behind trying to help others). Depending on what part of the ED I am in that day, I feel like I'm either drowning or really showcasing my abilities. Mostly, the more intense areas I do better with the fast track areas being harder for me. Mostly it's the speed of care. The easier areas I find it hard to chart in a timely manner and often find myself charting it all before discharge. So worried I'll be sued for missing something critical to add. (I hit the 6 month mark and the ER is my first RN job.) The longer stays, I can fully catch up even if it included CPR, bedside procedure, etc. Unfortunately, most of those include paper charting as well which is silly to me but admittedly sometimes makes charting faster if I have a hard copy to input from. I am finally starting to feel confident with my skills and I have finally gotten over the IV anxiety but there are still days where it hurts my confidence so much when I get multiple hard sticks in a row. My overall issues now are just those hard IVs and being able to anticipate orders and start them so I can catch up the charts. The mid level providers, a term I hate, tend to want IV sites more frequently so I'm starting to get better with timely care in that aspect but some days I just have to accept that I'm not where I want to be yet. I hate the days where I feel so rushed I have to rely on "muscle memory" if you will, as opposed to actual critical thinking. I feel like I'm not giving the best care I can even if it is just a simple issue like someone not educated on proper asthma management. I've learned to deflect the questions about food and beverage for the most part but appreciate ways you politely tell people no and when you decide it's ok. Also, and advice on how you chart effectively is helpful to me as well. My policy is q1h vitals for all patients which is seldom accomplished for my non-critical patients on a busy day. We use FirstNet through Cerner which I hate but any advice on what you chart and what you don't bother with would be helpful. I feel like mostly I might be over charting sometimes which slows me down.

Thisistara · Dec 14, 2017

Heyyy other new ED nurse. I'm at week 7 too and it's pretty overwhelming. The best thing I've been doing is working on time management. This thread is super helpful to read before a shift to remind you of what to focus on and how to prioritize time https://allnurses.com/emergency-nursing/time-management-strategies-272662.html. My preceptor is starting to get big on having all my stuff ready to go into a room and do everything in one trip, be ready to start the IV, know what kind of line and labs you need, put in protocol orders and do a mostly problem focused assessment and do the charting in the room instead sitting down and going back to do it later like on the inpatient units.

Its gonna be really stressful and overwhelming for the first year or so, ask for help and double check complicated meds with other nurses, don't worry about fumbling and being awkward cause everyone's expecting it from new people and it looks way better to jump in and try to learn.

Thats the the best advice I've gotten so far and I've found it wicked helpful. You can do it ðŸ‘

lainaa · Dec 14, 2017

Heyyy other new ED nurse. I'm at week 7 too and it's pretty overwhelming. The best thing I've been doing is working on time management. This thread is super helpful to read before a shift to remind you of what to focus on and how to prioritize time https://allnurses.com/emergency-nursing/time-management-strategies-272662.html. My preceptor is starting to get big on having all my stuff ready to go into a room and do everything in one trip, be ready to start the IV, know what kind of line and labs you need, put in protocol orders and do a mostly problem focused assessment and do the charting in the room instead sitting down and going back to do it later like on the inpatient units.
Its gonna be really stressful and overwhelming for the first year or so, ask for help and double check complicated meds with other nurses, don't worry about fumbling and being awkward cause everyone's expecting it from new people and it looks way better to jump in and try to learn.
Thats the the best advice I've gotten so far and I've found it wicked helpful. You can do it í ½í±

I agreee totally with this post.I am in the same boat as you.Some days I feel like Im drowning some days i feel like im barely getting by.Never have I felt like it was a great day. Its been hard transitioning to critical thinking because on the floor,all the planning for the patient was already done.I never had to anticipate whether or not this blood work is going be needed.or if they have this certain diagnosis.My preceptors have actually said Im always thinking abobe and beyond what their diagnosis would be.But I do try to narrow it down to a diagnosis more pertinent to how they present.As for charting.You can NEVER go wrong with over charting.You never know many years from now someone may bring you into court and you wont remember that patient.the only thing that would save your ass is you charting.im always automatically cycling my vitals into the computer,always documenting when i spoke to the doc and what was said,anytime a family member is acting out,etc.EVERYTHING NEEDS TO BE WRITTEN DOWN OR IT NEVER HAPPENED.save your ass now and youll thank yourself later.My hospital uses Epic and its a lot of buttoms but it took a while for me to get around navigating everything.itll get better.

TRY TO CHART IN REAL TIME.theres so many times where ive mentally assessed and seen my patient but I have not put it into the computer.Better place it in asap before you get caught up in another room and next thing you know,5 hrs has passed by and if you havent put that assessment in,it looks like you never saw them.Of course you can back time.but its better to do it THEN than later. Be proactive and ahead of the game before it gets nuts.we both know the ED never is dead.its always a **** show.Any advice on your end? I noticed that i am very unfamiliar of certain diagnosis and still need to get a hang of thinking quick..really quick on interventions that need to be done.ive been struggling.my preceptors and educators grill me so much and already have said theyre concerned.im just a slow learner.its discouraging to know that theyre not that helpful.i want to succeed and i will not quit!

lainaa · Dec 14, 2017

Thanks for this advice! In a similar situation and sometimes it feels so hard to focus on what I need to do. Some days I feel so ahead of the game and can actually finally take the time to ask everyone if they need help (Tried when I first started so I could show I'm a team player, and they mostly said to work on my stuff more because they knew I was new and didn't want to see me get behind trying to help others). Depending on what part of the ED I am in that day, I feel like I'm either drowning or really showcasing my abilities. Mostly, the more intense areas I do better with the fast track areas being harder for me. Mostly it's the speed of care. The easier areas I find it hard to chart in a timely manner and often find myself charting it all before discharge. So worried I'll be sued for missing something critical to add. (I hit the 6 month mark and the ER is my first RN job.) The longer stays, I can fully catch up even if it included CPR, bedside procedure, etc. Unfortunately, most of those include paper charting as well which is silly to me but admittedly sometimes makes charting faster if I have a hard copy to input from. I am finally starting to feel confident with my skills and I have finally gotten over the IV anxiety but there are still days where it hurts my confidence so much when I get multiple hard sticks in a row. My overall issues now are just those hard IVs and being able to anticipate orders and start them so I can catch up the charts. The mid level providers, a term I hate, tend to want IV sites more frequently so I'm starting to get better with timely care in that aspect but some days I just have to accept that I'm not where I want to be yet. I hate the days where I feel so rushed I have to rely on "muscle memory" if you will, as opposed to actual critical thinking. I feel like I'm not giving the best care I can even if it is just a simple issue like someone not educated on proper asthma management. I've learned to deflect the questions about food and beverage for the most part but appreciate ways you politely tell people no and when you decide it's ok. Also, and advice on how you chart effectively is helpful to me as well. My policy is q1h vitals for all patients which is seldom accomplished for my non-critical patients on a busy day. We use FirstNet through Cerner which I hate but any advice on what you chart and what you don't bother with would be helpful. I feel like mostly I might be over charting sometimes which slows me down.

I agreee totally with this post.I am in the same boat as you.Some days I feel like Im drowning some days i feel like im barely getting by.Never have I felt like it was a great day. Its been hard transitioning to critical thinking because on the floor,all the planning for the patient was already done.I never had to anticipate whether or not this blood work is going be needed.or if they have this certain diagnosis.My preceptors have actually said Im always thinking abobe and beyond what their diagnosis would be.But I do try to narrow it down to a diagnosis more pertinent to how they present.As for charting.You can NEVER go wrong with over charting.You never know many years from now someone may bring you into court and you wont remember that patient.the only thing that would save your ass is you charting.im always automatically cycling my vitals into the computer,always documenting when i spoke to the doc and what was said,anytime a family member is acting out,etc.EVERYTHING NEEDS TO BE WRITTEN DOWN OR IT NEVER HAPPENED.save your ass now and youll thank yourself later.My hospital uses Epic and its a lot of buttoms but it took a while for me to get around navigating everything.itll get better.

TRY TO CHART IN REAL TIME.theres so many times where ive mentally assessed and seen my patient but I have not put it into the computer.Better place it in asap before you get caught up in another room and next thing you know,5 hrs has passed by and if you havent put that assessment in,it looks like you never saw them.Of course you can back time.but its better to do it THEN than later. Be proactive and ahead of the game before it gets nuts.we both know the ED never is dead.its always a **** show.Any advice on your end? I noticed that i am very unfamiliar of certain diagnosis and still need to get a hang of thinking quick..really quick on interventions that need to be done.ive been struggling.my preceptors and educators grill me so much and already have said theyre concerned.im just a slow learner.its discouraging to know that theyre not that helpful.i want to succeed and i will not quit!