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

Editorial Team / Moderator · Dec 10, 2017

How many patients is a full load in your ER?

You really have to prioritize by ABCs - airway, breathing, circulation. Anyone who is trying to die more than your other patients comes first. Anything else is a nicety, not a necessity. Pain complaints make up about 70% of ER visits, so learn how pain is managed at your place - do your docs start with non-narcotics? Is IV acetaminophen (Ofirmev) available? That stuff is typically amazing, but is pretty expensive so not also carried everywhere.

Don't do a head to toe. Focus your assessments. But I did get in the habit of listening to lungs/heart on everyone, it just takes a minute and is good practice. I obviously add in bowel sounds on belly complaints.

If a patient tells you that they feel like they are going to die, believe them. Get EKGs on little old ladies with abdominal pain or who just don't feel well - I have caught a few STEMIs that way. 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.

You are going to feel silly and slow. Doesn't matter if you had 10 years of ortho/med-surg. That's just what happens when you go to the ER from anywhere else. Are you getting constructive feedback from your preceptor? How do they tell you that you are doing? Probably better than you think you are. :)

Good luck!!

lainaa · Dec 10, 2017

They actually have really worried me.They said that compared to everyone else in my group of 7,I am falling a bit behind.But in all fairness they allowed me to take a preplanned PTO vacay the first 2 weeks of orientation so I am behind my group by more than 72hrs on the floor.My preceptors-I have 4 which is irritating because every preceptor is different and expects different things from me.What I have been struggling with is thag clinical reasoning cycle and not being so caught up in tasks like I was used to my whole career.this is very new to me and im slow at it.In our trauma room,full load is 1:3 and our bravo room is 1:4 max.

Editorial Team / Moderator · Dec 11, 2017

Oooooh, yeah... Being two weeks behind the others is not doing you any favors because they are probably still going to be comparing you in their minds. Probably wasn't the best idea to take the vacation, but I assume it was something you couldn't reschedule. Bad timing.

lainaa · Dec 11, 2017

Oh definitely.I wanted to cancel the vacation but i had already planned it a year prior.Since my trip,I have been regretting that time off.But gotta just buck it up and do my best to persevere,focus and study hard!

nycRN3 · Dec 11, 2017

ED Nurse

nycRN3 · Dec 11, 2017

I am so annoyed I had such a thoughtful response and everything was deleted.

lainaa · Dec 11, 2017

I am so annoyed I had such a thoughtful response and everything was deleted.

Oh no!I am interested in reading your response.I need all the help I can get!

Miami_ER_Nurse · Dec 11, 2017

Over time, everything will become second nature. Utilize the nursing process. You have a patient in front of you, just looking at them is an assessment of its own. Investigate the chief complaint and try to think of the possible diagnosis's. Make your plan. ALWAYS think to yourself " what can i be doing now and what can be done next". Obtain vitals, ekg, line&labs without waiting for the doctor to tell you to do so. Treat pt then reasses and determine what needs to be done next. Example, i had a patient the other day that rescue brought in, hypotensive, brady in the 50s,cold clammy weak and complaining of chest pain. Already I'm thinking that this patient is a high priority based on looking at her. Im thinking she either is having an MI, aortic aneurysm, or possibly she might have taken her metoprolol and could be a reaction from it since she's brady and hypotensive. Immediately i throw her on fluids, R/O MI with an ekg and ask the doc if we should do a CTA of chest asap to R/O an aneurysm. CTA was negative, ekg was normal and BP went up after fluids and all labs were fine. The goal is to be on your toes and always be proactive and not reactive. Also, best advice for starting out in the ER, help out other nurses and if they're a great nurse, then they won't forget about you when you need help.

lainaa · Dec 11, 2017

Over time, everything will become second nature. Utilize the nursing process. You have a patient in front of you, just looking at them is an assessment of its own. Investigate the chief complaint and try to think of the possible diagnosis's. Make your plan. ALWAYS think to yourself " what can i be doing now and what can be done next". Obtain vitals, ekg, line&labs without waiting for the doctor to tell you to do so. Treat pt then reasses and determine what needs to be done next. Example, i had a patient the other day that rescue brought in, hypotensive, brady in the 50s,cold clammy weak and complaining of chest pain. Already I'm thinking that this patient is a high priority based on looking at her. Im thinking she either is having an MI, aortic aneurysm, or possibly she might have taken her metoprolol and could be a reaction from it since she's brady and hypotensive. Immediately i throw her on fluids, R/O MI with an ekg and ask the doc if we should do a CTA of chest asap to R/O an aneurysm. CTA was negative, ekg was normal and BP went up after fluids and all labs were fine. The goal is to be on your toes and always be proactive and not reactive. Also, best advice for starting out in the ER, help out other nurses and if they're a great nurse, then they won't forget about you when you need help.

Thanks for the advice!any pointers on how to shake the nervousness i feel when im overwhelmed with traumas coming back to back or pts coming in while one is already crashing? I know i can use my resources like my float nurse in my pod but not sure what else.

bgxyrnf, MSN, RN · Dec 11, 2017

Work to learn what are the legitimate emergencies associated with various complaints.

For example, a patient with lower back pain is usually a clinic-type patient who just needs some medication and a prescription. However, if that same patient has new onset fecal/urinary retention/incontinence, it may be cauda equina syndrome, a neurosurgical emergency.

Another example is with headaches. The vast majority of headaches in the ED fall into that same nonemergent category. Give them an IV cocktail and send 'em on their way. However, a patient with a sudden onset, focal headache - especially in someone who doesn't typically get headaches, could have an aneurysm and needs a STAT head CT.

Regarding IVs: Mastery takes practice. When you get a new patient, find the best vein that you can... for example, a big, plump AC... then find one that's kinda sketchy and try that one, knowing you've got a fall-back if you need it. You don't get better sticking the easy ones.

Early in my ED career I relied on two books: Sheehy's Manual of Emergency Nursing and Emergency Nursing Procedures by Jean Proehl.

Ambersmom, BSN, RN · 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!