ED basics, as if there was such a thing...

[maydaymalone]

Hello all,

I'm a Level I (of IV) nursing student in a BSN program interested in working in an Emergency Department.

Obviously I've got a long way to go before graduation (May '13), but I was hoping some of you who already have experience working in the ED could give me a few topics that I can research on my own time to advance my learning.

I realize you see everything from bunions to brain damage, but I was specifically looking for the most common critical cases you encounter. For example, if someone presents with chest pain, you would do X, Y, and Z and I need to know about drugs A, B, and C.

What are the most common, but critical cases you see regularly, and what drugs do you administer frequently? Chest pain, trouble breathing, stroke, MI, gunshot or stabbing, other?

Thanks for your time and replies.

[surferbettycrocker]

i agree get a tech gig ifyou can. also consider trying med surg or telemetry after nsg school if you are unable to get directly into the ER. it will prepare you for the hustle and bustle.

and chest pain is a big thing in the ER . EKG vitals are always a good start. but not all chest pain people are the same.... sometimes nitro will do much more harm than good depending on what the underlying patho physiology of the patient is. and pumping up a blood pressure with intravenous fluids can in some instances, create a whole new set of issues. but thats for the 'floor nurses ' to deal with once you get the birds relatively 'stable' and up to the floors.

but thats above board for your question. just some food for thought like one poster said 'not everyone is a turkey' remember that. especially when your 90 year old grandmamma comes in at midnight because of a horrible 'toothache'

[Christy1019, ASN, RN]

CP =02,Monitor, IV, ASA, NTG Every time.

We were always taught to remember MONA for chest pain; Morphine, O2, Nitro, Aspirin

[Christy1019, ASN, RN]

Don't stress yourself out trying to remember all of this, I didn't learn about RSI (rapid sequence intubation - which means you need to secure an airway so you sedate them so they are unconscious and give them a medication that paralyzes the patient so that they aren't working against your efforts to ventilate them) until I was working in the ER, and even then it took me a while to remember the meds b/c our ER has our own pharmacist who is generally gonna be there during most intubations. ACLS is definately very complicated for you to try and understand this early into your education, in my DEM we are not scheduled to even take ACLS until we have been off orientation for one year and by then have had our critical care course. Plus the ACLS guidelines change almost every 2-3yrs, so what you try to make yourself learn right now may be outdated when the newer guidelines come out. (they are constantly changing the recommended protocols for resuscitating a patient based on research studies and compiled results of patient outcomes), all you need to focus on for the time being is BLS which is half of what makes up ACLS.

The absolutely MOST important thing you need to remember, and ALWAYS apply it to your nursing practice is the ABCs.

AIRWAY is ALWAYS ALWAYS the first thing you are check... regardless if they came in w/their leg amputated and bleeding everywhere, you always make sure their airway is clear and that the patient is able to maintain their own airway, otherwise you secure that airway for them i.e. intubation.

BREATHING; only after assessing the airway do you move on to the next step, Breathing. for example; patient comes in via ems with severe facial trauma. they say patient isnt breathing and therefore they are attempting to ventilate him with an ambubag. You remember to always check airway first, and when doing so you find that the patient is barely conscious and has a lot of blood/broken teeth etc in his airway. you clear his airway with suction and open his airway with jaw thrust maneuver (replaces the head tilt chin lift method b/c of risk for spinal injury). after doing that, the patient begins to breathe on his own b/c now his AIRWAY is clear!

Circulation: after your airway is secured and the patient is breathing adequately or is being ventilated, you now will check for a pulse, and if there is one, assess if it is weak and fast, or strong and bounding, or maybe you can feel their central pulses (carotid/femoral) but cannot feel their radial/dorsal pulses, which is an indicator of shock/blood loss/heart failure. if there is NO pulse, then you immediately begin CPR and would then follow the ACLS protocol to attempt to resuscitate the patient with CPR, medication, defibrillation and ventilation. The most important part of any resuscitation is GOOD CPR, avoid interrupting compressions, which should be approx 100 compressions per minute. One of my favorite MDs taught me a trick to remember not to compress too fast or too slow, compress to the beat of the song "Staying Alive" by the Beejees.. the beat of the song is exactly 100 beats per minute lol. if you do compressions too fast you are not giving the heart sufficient time to fill back up with blood before being pumped back out nor will the lungs be able to absorb enough oxygen before you push it out. if you go to slow, you are not providing enough pump for the brain to be perfused with oxygenated blood and the brain cells will begin to die.

If you want to get an idea of what ACLS is like, there is an awesome ACLS/MEGACODE SIMULATOR app that is up to date with guidelines @ WWW.TRAUMAMEDIC.COM, click on quizzess/tests, and its the first link. be sure to read the algorithms and med review first or you won't stand a chance, but you can at least see what ACLS is all about.

I agree with the above poster about getting a tech or extern position in the ER prior to graduation, because it is a LOT to have to learn as a new nurse and is much faster paced so having prior experience will definately benefit you.

good luck with everything, when it starts to suck and you think you will never graduate, just remind yourself that it's just school, once you graduate you don't ever have to do it again! lol

[brainkandy87]

Well, I just moved to the ER and I tried to do a lot of studying ahead of time. I knew a lot of the basics because I precepted down there in nsg school. A lot of it has already been mentioned for CP, abd pain, DKA, etc. However, I think the biggest advice I can give is this: use the nurses you have around you. No one can know it all, but the ER nurses that have been around the block a few times.. their value cannot be measured.

I work with some great ones in my ER and when I was a SDU nurse, I worked with a 30+ year vet of the ER. I became 10 times the nurse I would've been at this point had I not worked with him. Soak up the knowledge of your coworkers.

[CrashED]

I worked a Gensurg/Urology/vascular surgery and stepdown unit for a # of years before I thought I was ready to embark on the adventures and controlled chaos of emergency nursing! I thought I was ready was the key point....you are never ready down there! you can study everything but you need to slowly become the jack of all trades master of none you become the educator, discharge planner, support system, advocate and gatekeeper for all patients! Whether you are a level 1 trauma center or a level 5......you sometimes are running the show with your license on the line! Everyday is a new experience, and you never know what is coming through the door...that is the beauty of emergency nursing. You learn something new everyday!

FIRST THING YOU NEED TO KNOW WHEN YOU GO TO AN EMERGENCY ROOM IS HOW TO ASSESS A PATIENT! THEN WHAT ARE YA GONNA DO ABOUT IT?! Know all the big and bads with each system....as well as your ACLS & RSI and go from there. I have given everything from amoxil to etomadate in a 10 minute span!

[Christy1019, ASN, RN]

CP = 12lead ECG, line and lab (iv and pull stardard labs, we call it a rainbow), O2, asa (aspirin), nitro (remember only one not the whole bottle), monitor, CXR

Syncope = 12 lead, line and lab, Accucheck (bedside blood glucose), CT

Abd pain = 12 lead, line and lab, UA

DKA = 12 lead, line and lab x2, Accucheck, foley, fluids

For syncope i'd also do orthostatic VS and if related to trauma i'd order a head ct (our facility let's us order them in triage to r/o bleeds quicker), and depending on what lead to syncope or any resulting trauma, place a c-collar on the pt.

I'm wondering why you would need a foley for DKA pt? I know you want to monitor I&Os and efficacy of fluid replacement, but if the pt isn't confused and ambulates w/out difficulty, a foley would put them at unneccessary risk for UTI. Even if the pt requires a bedpan b/c of physical impairments, I would still avoid a foley unless they were incontinent with skin breakdown, intubated/unconscious, urinary retention, etc.

I don't mean to sound like I'm criticizing, just interested in your reasoning, maybe ill learn something new lol :-)