ICU to ER nurse = HELP ME PLEASE

  1. I landed a job in the ER at a rural-ish hospital very close to home, best pay of my nursing career, like the facility/staff/job itself.
    But I'm in ICU to EM transition HELL.
    I googled & reached out to some online posters in various forums who posted/commented about this but am hoping for more specific feedback now that I've narrowed down my questions. The transition is a nightmare.
    Hx: tele, m/s charge, ambulatory clinic nursing and some ambulatory procedural ICU - cardiac/neuro/medical unit in a mega academic center, transplants, SWAN/CRRT anything that moves, early progressive ambulation with vents just waltzing down the hall with their IV pumps full of gtts, IABP, VADs, Impellas, helping residents learn and build teamwork skills, anticipate needs and ability to prep for just about any bedside procedure including RSI drugs except no bedside ex-laps
    Current problems in some order;

    1. Slow with tasking IV/labs/cath/EKG while simultaneously going through the questions for the chief complaint. I can dart in a 18g, draw my labs, 12lead, in & out cath and get monitoring on in less than 15minutes but I just don't "know" all the things for each different variety chief complaint to ask and when I have enough data for EM needs.
    *for this I would be eternally grateful if anyone has chief complaint quick reference guides or example order sets*

    2. Wrapping up charting. So the software is horrible and archaeic and just bad. I'm adjusting, I type 70-80wpm, just remembering where and what ******* F key does what. Learned the enter key on the numeric pad is evil and not equal to the other enter key in terms of functionality and mistakenly deleting entire sections of my charting. I really hate charting at the bedside. I'd rather chart at the desk. Thoughts?

    3. Speaking of charting- if I did a damn neuro exam but charted under neuro reassess and not the abbreviated mini NIH tab (which is way less info but the SAME as in other too) I got a nastygram for it. Bc surveyors might miss it under that other title. SPARE ME PENCIL PUSHER.

    Of note: we don't have techs. We do it all from start to finish. Team nursing. But I'm being oriented with 4 rooms solo to fully grasp the entire enchilada.


    So great minds that be, give me your best advice, spare me the encouragement "you'll get it keep trying" nonsense.
    fellow nurses... assume you like working with me and my potential is there, just need me to do what better/differently?
    I want straight up advice only. I really want to hear what matters most to you from your coworkers and what you could give a **** less if they did or didn't do.
    Please and many thanks to any contributions.
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  2. 4 Comments

  3. by   nurse2033
    If you are in orientation they should be teaching you not flogging you. Either way, this won't cure your problems overnight but we use Sheeheys Sheehy's Manual of Emergency Care - E-Book (Newberry, Sheehy's Manual of Emergency Care) - Kindle edition by ENA, Belinda B Hammond, Polly Gerber Zimmermann. Professional & Technical Kindle eBooks @ Amazon.com. as part of our orientation for new ED nurses. Good luck.
  4. by   2mint
    OP, seems like you already know the flow of the ED, and as for charting, we have check boxes for the "ABCD", then free-text box for CC/HX/etc.

    What you really want to know is the CC and their associated symptoms: I'll give you the two common ones:

    CC: CP
    1. PQRST
    2. Associated sx: SOB, dizziness, N/V, diaphoresis, cough, fever, chills

    CC: Abd Pain
    1. PQRST
    2. Associated sx: N/V/D/C, GI bleeding, Fever/chills, Etoh use, dysuria, hematuria, LMP

    If you're still in orientation, why not just ask your preceptor? (e.g., "Hey, for abd pain, I asked these and these, what else am I'm missing? or something equivalent).

    Good luck.
  5. by   JKL33
    Quote from JustKeepSmiling
    1. Slow with tasking IV/labs/cath/EKG while simultaneously going through the questions for the chief complaint. I can dart in a 18g, draw my labs, 12lead, in & out cath and get monitoring on in less than 15minutes but I just don't "know" all the things for each different variety chief complaint to ask and when I have enough data for EM needs.
    *for this I would be eternally grateful if anyone has chief complaint quick reference guides or example order sets*

    2. Wrapping up charting. So the software is horrible and archaeic and just bad. I'm adjusting, I type 70-80wpm, just remembering where and what ******* F key does what. Learned the enter key on the numeric pad is evil and not equal to the other enter key in terms of functionality and mistakenly deleting entire sections of my charting. I really hate charting at the bedside. I'd rather chart at the desk. Thoughts?

    3. Speaking of charting- if I did a damn neuro exam but charted under neuro reassess and not the abbreviated mini NIH tab (which is way less info but the SAME as in other too) I got a nastygram for it. Bc surveyors might miss it under that other title. SPARE ME PENCIL PUSHER.
    Honestly, it sounds like you're developing a better handle on things than you give yourself credit for.

    1. As far as everything that needs to be done right away - - I feel your pain. I really can't imagine doing it in a timely manner without techs. Some of these people take 10 minutes to sit on the dang stretcher and get the gown on. However, you will learn to multitask and ask pertinent questions while getting the important tasks done quickly.

    Regarding "quick reference guides" - - I agree with the text mentioned above. My personal preference in mentoring nurses new to the ED, though, is to focus on the thinking behind what we're doing. I understand the desire for some sort of guide i.e. what to do for "chest pain", "abdominal pain", etc. The problem is, that isn't foolproof, and isn't as good at helping develop the ED version of critical thinking. I encourage you to aim for developing into a ED RN who is a "thinker and do-er" rather than a "task-er", if that makes sense. I've seen places where they give out big binders with pages for each condition which contains a list of "what to do" - - the problem is, for someone without ED experience, how do you know if you should pick the "diverticulitis" page or the "incarcerated hernia" page or the "UTI" page or the "nephrolithiasis" page or the "leaking AAA" page?? Some of the initial steps related to these things might be similar, but there's a lot of knowledge involved in knowing which way to head first. We do new ED nurses a disservice by not aiming to help them broaden their knowledge base first and foremost. You have a lot of experience to draw from so you're in a great position. I believe that better care is ultimately rendered by those who choose to learn how to think in the environment in which they're working (so long as they can also get things done in a timely manner).

    2. Unless I am involved in a situation that requires 1:1 care or doing meds/allergies and PMH, etc., I don't chart too much at the bedside. Personal preference. I find it too distracting (esp patient/visitor conversations/TV/phones/kids running around, etc) and prefer to be focused on the patient or else not in the room.

    3. Agree. And I do not double chart anything. It's against my religion. Over time you will learn the preferred area for charting various things and will get better at putting it where they want it, but I usually chart it in the most sensible/accessible/convenient area and leave it at that. Sometimes I will go to an area that I know is being tracked and make a note that says "see neuro exam." Simply because it's the principle of it. I've already charted it somewhere else that I was told I needed to chart it. Done.

    As to your ultimate question - what is most important to me? Critical thinking. My recommendation related to this would be to get a good text like the one mentioned or the CEN book and study @ home. Take even ½ hr each day and review the conditions you encountered that day at work.

    Best of luck!! And I DO think you will do just fine!
  6. by   TaylorBean
    Just like you, I went from ICU to ER. The first 6 months is rough. The flow is different, the documentation style is different. What do you mean you give antibiotics without a pump? :0) In such a fast paced environment what I have learned is to acknowledge when I need help and ask another nurse to help me with starting the patient care tasks while I document. This is great when you get 2 ambulances one after another. Or get a STEMI, code etc. Another thing that helps me is memorizing what questions are needed for your initial documentation and asking the patient while you are performing initial patient care. This takes time! But once you get it down it makes the process faster.

    For example, I'll walk into my pt's room who just got here by ambulance for abdominal pain. I will get quick report from EMS then ask pt "What brought them to ER today"? As the pt is talking I will be listening and doing initial vital signs. Then setting up for IV, labs. Based on what the patient tells me will I then ask more detailed questions.

    "I've been having diarrhea and I have stomach pain".

    From what the pt states I will then ask how long this has been going on, color of diarrhea, frequency, last episode, description on pain. Sick contacts, recent travel, febrile, recent antibiotics etc. By now I'm doing IV, lab work. After time you memorize what you say and what patient says.

    When I was thinking like an ICU nurse working in ER I would ask nausea, vomiting, and more questions. Write every detail down or bring computer in room. But as time has went on, I focus on what brought the pt here and what they state the symptoms are and what questions are the most important to ask regarding their chief complaint. If a pt does not state they were nauseas or having vomiting I am not going to ask on my initial assessment.

    When I am doing line/ labs I am asking the patient the questions that are required for triaging per my institution ex. Have you thought about hurting yourself recently. How much alcohol do you consume per week. Smoking status etc.

    Once I am finished I can document -not at bedside! The only thing I document bedside is if I am going over medication list and the pt does not have an updated list. If a pt has a med list bring it with you to nurses station, document them when you get a chance and then give it back to pt.

    As a resource the best thing I could have done is on my badge make a badge of references. One important reference is range dosing for RSI, even though you come from ICU I found that the ER can use different RSI meds- some that I've never used on the unit. It's always good to have a quick reference badge.

    Recently the most helpful thing to me was the "Dirty Epi drip". I had that written on my badge.

    After 2 years in ER I will never go back to ICU, I love it and have found my calling. I wish you luck and hope you get past your orientation. Message me anytime.

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