Feel stupid

Specialties Emergency

Published

I am a brand new nurse and my first job is ER. I've worked other areas of healthcare but this aspect is new to me.

Calling report to the floor makes me feel stupid. They ask questions that I don't know the answers to because I see the patient for a very short time.

One occassion that I really was stupid was when the nurse asked the patients blood sugar. I had to look it up and it was 270. Crap, I hadn't even realized the patient was diabetic and I should have known if I put two seconds thought into it. I had managed to hang her antibiotic. I had called pharmacy to discuss a potential allergy to the med I had hung but I hadn't reviewed her lab values prior to report. I was darting between two other patients one of which I couldn't get an iv access on. The patient was in the ER for less than two hours before being admitted. How big of a mistake was this?

Up Vote Up Vote ×

Honestly, I wouldn't worry about it too much. You're not the only one reviewing labs- the drs are too. The ED dr planned on admitting patient and chose to let the floor handle the patient's diabetic regimen. The inpatient dr surely reviewed the patient's labs too. Maybe the patient doesn't use insulin and normally controls his/her bg with diet. There are a lot of variables that could be in play. I can tell you in my own ED we don't typically manage bg unless that's the reason they came, ie DKA, etc. 270 wouldn't rate much of an eyebrow raise and the floors will have the patients on a schedule for insulin, should they need it. Take it as a learning experience and ask next time.

As for report, here's the thing I have learned from being a floor nurse and transitioning to the ED- our focus is so different that sometimes we can't know the answers they want. We only do focused assessments while they are usually required to do full assessments. If a floor nurse asks me something I don't know about the patient, I say I don't know. If they get crabby I remind them of the difference between what they do and what we do. Nicely, of course. Then again, there are the floor nurses that want you to do their full assessment for them too. I try really hard to give good, thorough reports but really, our report is no substitute for their own assessment, no matter how much they want it to be. Shake it off. And if there's something you could be doing better, like a consistent thing you're hearing when you give report- then focus on that. I already know what a lot of the floor nurses want- how do they ambulate, what does their skin look like, what is their living situation? I try to get those answers up front and then just focus on my own assessment. Hang in there.

Up Vote Up Vote ×
Specializes in ED, Cardiac-step down, tele, med surg.

I have no problem telling the next nurse I don't have the answer. Thankfully my hospital uses electronic charting. If I don't know the answer, I tell them to look it up. Was the patient there for hypoglycemia or hyperglycemia? If not, you didn't make a mistake, the floor nurse can check the sugar when the patient gets upstairs.

Up Vote Up Vote ×

Thank you! That's what I thought but I still think I should have realized this particular patient might have an elevated BG. The nurse asked and it was a Duh moment. Even though it was only peripherally connected to the reason the patient was being admitted. Oh well, live and learn.

The tip about paying attention to the home family situation is a good one. Thank you!

Up Vote Up Vote ×
Specializes in Emergency nursing.

I agree. I transitioned from the floor to the ED back in 1993. Long long ago.. Was terrified to give report. In the ED that BS

was not a life threatening situation. The focus is on what can kill them and what we need to fix to prevent just

that. If his potassium was 2 and that you did recognize then that is different. or if his BS was 30. Critical

thinking and critical values. There will be days that you are not gonna have all the "tidy" package answers

Also EMR are very nice now everyone can review the record. Critical thinking will come. Find a good mentor

Encourage the floor nurse to come and spend a shift with you!

Up Vote Up Vote ×
Specializes in Medical-Surgical, Emergency.

You'd love my hospital then ;P They've come up with this system where we print out a "SBAR" sheet that is automatically filled in with hx, vs, meds given, IV site, etc. etc., we fax it to the receiving floor. Then we call them and say "I've faxed the SBAR, the patient will be leaving in 15 minutes, if you have any questions you can call me back. Buh bye."

I'm still not sure it's the best, safest, or most efficient way of moving patients. But it's our policy for now, so I'll play along.

But to get back to you dealing with your situation. Definitely agree with jguiney. You may have over looked a BS of 270, but that's not a life threatening emergency. They're not in DKA. That's a discharge-able blood sugar if nothing else was going on. Further in the situation, obviously, the ED doc saw it, the hospitalist saw it, no one ordered any insulin. It's not a biggy. I don't mean to imply we should rely on the physicians to do all the critical thinking, but in this case, the 270 glucose was definitely not a concern. A lot of diabetics are walking around the mall at 300+ lmao

You'll get better at report, but your report and their report are just vastly different. Like CX_EDRN said.. sorry, while I was stabilizing their respiratory distress, I didn't manage to find out if they use, have a sore on their bum, have community support, and got their flu shot this year. Seriously, get off my ish. They couldn't breathe, now they can, they're coming to you, you can do your job when they get up there, I've a code coming to my other room.

Up Vote Up Vote ×
You'd love my hospital then ;P They've come up with this system where we print out a "SBAR" sheet that is automatically filled in with hx, vs, meds given, IV site, etc. etc., we fax it to the receiving floor. Then we call them and say "I've faxed the SBAR, the patient will be leaving in 15 minutes, if you have any questions you can call me back. Buh bye."

I'm still not sure it's the best, safest, or most efficient way of moving patients. But it's our policy for now, so I'll play along.

But to get back to you dealing with your situation. Definitely agree with jguiney. You may have over looked a BS of 270, but that's not a life threatening emergency. They're not in DKA. That's a discharge-able blood sugar if nothing else was going on. Further in the situation, obviously, the ED doc saw it, the hospitalist saw it, no one ordered any insulin. It's not a biggy. I don't mean to imply we should rely on the physicians to do all the critical thinking, but in this case, the 270 glucose was definitely not a concern. A lot of diabetics are walking around the mall at 300+ lmao

You'll get better at report, but your report and their report are just vastly different. Like CX_EDRN said.. sorry, while I was stabilizing their respiratory distress, I didn't manage to find out if they use, have a sore on their bum, have community support, and got their flu shot this year. Seriously, get off my ish. They couldn't breathe, now they can, they're coming to you, you can do your job when they get up there, I've a code coming to my other room.

Thank you! At least that method would eliminate the ten minute hold while "let me get that nurse."

Up Vote Up Vote ×

My ER also faxes a report with all of the pertinent ino to the floor. I do my quick head to toe and focus on chief complaint. If I have to give report I focus on how stable they are and what we are dealing with. Maybe let them know what med I passed and what they need next and their vitals. The other poster is correct. They need to do their own assessment. We are extremely busy and I will go thru 20+ patients in a shift. They have the same 6 all day usually. I am getting rescue after rescue and I need to stabilize them. Don't be too hard on yourself. If you have never worked in an ER than they don't know what we deal with. Getting an ER position as a new grad is an accomplishment in itself. Critical thinking will come with time. I always ask myself what could cause the patient to deteriorate and focus on that. Most floor nurses would have a tough time dealing with the pace of the ER. I say that because we have had many try to convert and wouND up going back to their original floor. ER is rewarding since you can see what you did makes a difference.

Up Vote Up Vote ×

Prefer to take a quick second-look at labs before I call; mostly because I like to give them an organized and concise report. Then when they start asking about incidentals I can confidently reply "I did not assess that" or "that was not part of our focus down here". I make no apologies about not having the answers to things that were not relevant to stabilizing the patient's condition. I have this fantasy that they'll eventually learn that my role is not the same as theirs, and that it's OKAY.

I know we're so busy but I do think that taking 60 seconds to review what you know about the patient and kind of summarizing their problem in your own mind will help you gain confidence both in calling report AND (more importantly) in training yourself to see a 'big picture' when given a relatively small amount of information. In fact I would recommend that you do this periodically while you're caring for your patient load. Just keep reviewing...'what do I know so far?' 'How is my patient looking now?' Early in our career we sometimes tend to focus on our task list, it's only natural. But you'll come out ahead if you train yourself to see a big picture of each patient and understand what we're trying to rule out/rule in, and why we're doing what we're doing. Ultimately, that's what our task list flows from anyway. :)

Up Vote Up Vote ×
Specializes in ED.

Hey Cat365! Welcome to the joys of ER nursing!

I also started in the ER as a new grad and I gave some cringe-worthy reports at first for sure.

All the advice the previous posters gave you is right on. The floor nurse can look up a Potassium level, or an order for sliding-scale meal time insulin in the EMR just like you! I mention Potassium because I still remember a floor RN asking me "What's the potassium?" and I was mortified I didn't know the answer off the top of my head - even though it wasn't a critical value and wasn't even relevant for the pt's condition. Ugh, it sucks to be a newbie. You don't even know when you can/should push back....

However you definitely don't want to be caught with your scrubs down not knowing a critical value. We were taught to use this I PASS THE BATON tool during orientation in my ER - I hated it, it is so dry and formal, but I made myself use it (I printed out a bunch and just went down the list with the info I would fill in).

After dozens of reports and a couple dozen shifts I didn't need the paper anymore it was ingrained, It was a good blueprint but I didn't need that much formality or detail, and I found myself jotting down things I knew I would want to remember for report on my own cheat sheet so as soon as my pt got a room I was on that phone.

I am also always super respectful and polite when I call and try to bring good humor to the nurse I am reporting to; I give everyone the benefit of the doubt, and esp if they sound cranky I try to lighten the mood with a "how's your night, is it awful up there too?" We are after all allies, not enemies. Sometimes you just get a cold stubborn impossible to please colleague - but hey that's not on you, pt's stabilized and going to the floor and that's that.

Wait till you give your first ICU report (GAG!!). I think I sweated through my scrubs thoroughly! But again, with experience you learn to start planning for that report on an ICU pt early. Here's a good laugh at how ER to ICU reports generally go:

Emergency Room Gays | Transferring care of an ED patient to a veteran...

Hang in there - time and experience heals all newbie wounds!

[TABLE]

[TR]

[TD] I[/TD]

[TD] Introduction[/TD]

[TD]Hi this is XX in the ER with report on pt going to 526b[/TD]

[/TR]

[TR]

[TD] P[/TD]

[TD] Patient[/TD]

[TD] Name, identifiers, age, sex, location (Pt John Doe; 55 yo male....)[/TD]

[/TR]

[TR]

[TD] A[/TD]

[TD] Assessment[/TD]

[TD] Present chief complaint, vital signs, symptoms, and diagnosis[/TD]

[/TR]

[TR]

[TD] S[/TD]

[TD] Situation[/TD]

[TD] Current status or circumstances, including code status, level of

(un)certainty, recent changes, and response to treatment[/TD]

[/TR]

[TR]

[TD] S[/TD]

[TD] SAFETY Concerns[/TD]

[TD] Critical lab values or reports, socioeconomic factors, allergies, and alerts

(eg, falls or isolation)[/TD]

[/TR]

[TR]

[TD=colspan: 3] The[/TD]

[/TR]

[TR]

[TD] B[/TD]

[TD] Background[/TD]

[TD] Comorbidities, previous episodes, current medications[/TD]

[/TR]

[TR]

[TD] A[/TD]

[TD] Actions[/TD]

[TD] What actions were taken or are required? Provide brief rationale[/TD]

[/TR]

[TR]

[TD] T[/TD]

[TD] Timing[/TD]

[TD] Level of urgency and explicit timing and prioritization of actions[/TD]

[/TR]

[TR]

[TD] O[/TD]

[TD] Ownership[/TD]

[TD] Who is responsible (admitting service? team?) any family contact info[/TD]

[/TR]

[TR]

[TD] N[/TD]

[TD] Next[/TD]

[TD] What will happen next? Are there anticipated changes? What is the plan?[/TD]

[/TR]

[/TABLE]

Up Vote Up Vote ×
Specializes in Emergency, Trauma, Critical Care.

I still suck at giving report and I used to be an ICU nurse. I know why they're there and what I did to stabilize them. We actually do a written report and call the floor nurses and make sure they read it and if they don't have questions attention is on their way....

Up Vote Up Vote ×
Specializes in Emergency Dept. Trauma. Pediatrics.

You will probably soon learn this is going to be long term battle. LOL You'll get better and more efficient at it and realize even so it's never enough. You'll find yourself beyond frustrated having to give report when all these absurd (to us) questions are asked, and they will hate getting report for you. It's a no win situations. Not always, sometimes you get amazing people that just want the down and dirty in report and you will rejoice and your faith will be restored.

I try to play nice but and most times it's all good but I am pretty sure various units through the years had my name and photo up as a warning if I called to give report. LOL

I once had a nurse that kept asking the most absurd questions (again to me at least) and I finally lost it when they wanted to know which nare the NG tube was in. I told them it was a gonna be the left or the right and if they couldn't figure it out on their own they needed to rethink nursing. I have had nurses call back down to the ER an hr later "that patient you sent up is having chest pain again" :| :| Ummmmm do an EKG why are you calling me??? "That patient you sent up was doing good but now their BP dropped really low again" Well you're not sending them back down here. What the heck. :|

Up Vote Up Vote ×
+ Add a Comment