Currently on orientation at a level 1 trauma ER,help! - page 3

Currently I am orienting to the ER at a level 1 trauma center.I am on week 7 of 12 now.I only have previous experience on an ortho/medsurg floor and worked at an allergy practice as well.I still... Read More

  1. by   Phenomenurse
    Hang in there...

    if you're deeply unhappy thats a different story, follow your gut. But if the problem is just the challenges of coping with emergency nursing, hang in there.

    I started in the ED and am going on 2.5 years now, I still have challenging days and I don't predict any real form of professional "comfort" until I hit 5 yrs at least. The ED itself is so varied, you can't get accustomed to any one thing because every day and every patient is so different and unpredictable, but thats one of the cool things about the ED too...
  2. by   KeeperMom
    Don't be too hard on yourself. The ER is a very different animal from the rest of the hospital. It is ever-changing and an ER RN has to be able to anticipate and recognize those changes. The ER nurse is the chameleon of the hospital.

    Knowing your ABCs is a priority always. Your seemingly stable 26 year old with an allergic reaction takes priority over your stable 80 year old papaw with the broken arm. Sounds odd, right? But those younger allergic reactors will turn on you in a heartbeat (no pun intended).

    You've gotten some great advice already by some of our seasoned ER nurses here. The only thing I can add is based on experience as a coach. I've seen so many nurses struggle with the timing of everything; the charting, the assessing, starting an IV, labs, etc. It is all overwhelming.
    I've noticed that so many newbies go straight to that computer and start her charting but never include what the patient actually says. We ask a lot of the same questions in the ER and we are so hot to get all of that documented that we forget to actually lay hands on the patient. Our charting software is template driven so what I'm telling you is based on that....
    I tell my new orientees to drop your template in the computer to time stamp the patient and you in the room. After that, step away from the computer and go touch your patient. You can ask all the questions you need to ask while you are putting your patient on the monitor and then doing your assessment and then starting your IV and drawing blood. You can go back to do your charting after you assess if you can't remember it all.

    When I chart, I also try to include, "The patient states.....XYZ" I always give his CC, duration, other associated symptoms, other episodes, and other pertinent information. Just answering the template isn't enough. If your patient's CC is abdominal pain, you need to include the type of pain and where the pain is in the belly; LLQ, RUQ, etc.
    ie: Pt c/o RLQ "cramping" abdominal pain x2 days. Pt reports associated N/V/D with fever and chills since onset of s/s. Denies melena or hematachezia. Denies sick contacts. States OTC antiemetics have not improved s/s. Denies any new or changes to current medications.

    Again, all of this is thinking ahead and asking the pertinent questions to help you and your MD determine a plan for the patient. If your dept has protocols you can initiate, know those backwards and forwards. Knowing why we are ordering these tests will really help you, too.

    All of this is definitely overwhelming at first and a lot different from working on the floor in any other unit. The ER is the front line and we are starting with a clean slate with each and every patient and every one of those is different.

    Best advice? Listen to your patients - not just what you hear through your s'scope but what the patient is saying and what he/she is NOT saying sometimes. And trust your gut. If is smells like a rat, it probably IS a rat.
  3. by   HermioneG
    I just got off orientation and there are three very solid pieces of advice that stand out:

    First is that in all kinds of nursing, but ER especially, its important to be tuned in to what one of my preceptors calls the "steps to an emergency." Example: you have a patient who has an increased work of breathing and a SpO2 on the low side. Its easy to get overwhelmed with the history, physical, meds, treatment, plan, etc etc and in getting swamped under everything ultimately missing the bigger picture (especially as a new grad). What is critical in these situations is identifying way before hand how many steps of interventions can occur until a true emergency happens. Back to the patient who is short of breath. What level is this patient at, what can we do right now, and what is the next step for when this current level of intervention doesn't work? How many steps does our team have before this patient reaches a fatal level? This would be my line of thinking (again I just got off orientation so I'm sure more seasoned nurses might have a different opinion and I'm always eager to learn) for a patient who presented with shortness of breath.

    In the case scenario with the increased work of breathing and low SpO2 patient. While there are many variables, treating this particular problem has a basic skeleton ladder of steps in which you can escalate treatment until this patient is dead, or the patient can travel back down a level if the intervention works and the patient's condition improves.

    No intervention: room air
    Level 1 of intervention: sit the patient up and put them on a nasal cannula. If that doesn't work and the patient is still tachypnic with low O2 sats then notify the physician and escalate to:
    Level 2: simple mask (our facility usually skips this step)
    Level 3: non rebreather at 15 L/min
    Level 4: BiPap
    Level 5: Intubation

    Sure, there might be other steps we could throw in there but that is a pretty basic skeleton of how you could escalate if needed.

    So, when your patient is tachypnic and short of breath instead of freaking out, ask yourself how many steps there are to an emergency and/or patient death. Look for your resources and communicate. Let the nurses around you know of the situation "hey heads up my SOB patient over here is not looking too great this is whats going on right now, and I'm going to let the Dr, Charge, and RT know." That way if your current level of intervention doesn't work and you have to escalate quickly your team and those around you know what is going on.

    This same preceptor told me that ER nursing is about communication and utilizing your resources. Know how to access policies online, the online drug library, etc etc. Also, don't just look at a patient problem and see it as stagnant. Understand that things can escalate quickly and so its critical to know what resources you have on hand and steps you can take before/during/after the situation turns critical.

    My other preceptor, when I was talking about how overwhelmed I was all the time, told me that ER nursing is like playing a sport. I like to personally compare it to baseball. In the beginning the game is going to move incredibly fast. You're going to mess up, strike out, and things are going to blow past you sometimes. But, as you learn the game and get more practice you're going to start actually seeing the ball as it passes in front of you. Instead of striking out constantly and just swinging and wondering where the ball went you're going to start making contact. The game will slow down, and you're going to start feeling better about it and it gets fun. It will get better, you just need to get through this phase and make sure you don't hurt anyone and have a good team to back you up.

    The third thing I want to share that BOTH of my preceptors told me is that nursing is a 24 hour job. There will be days where the opposite shift nurse is going to hand you a mess. There will be other days that you get swamped at shift change and you hand the other nurse a mess. Forgive yourself for it and just try your best. Help out whenever and wherever you can.

    You'll do great just keep pushing through!