New Grad Starting in ED - Advice on Good Assessments

[ecf1972]

Hi all,

I graduated in May and will be starting my first job as an ED nurse next week. I was wondering if any of you experienced ED nurses could share with me initial assessments that you have found to prove helpful over the years. I had the opportunity to shadow a RN before I accepted the position and he had a really good flow with his questions that he asked his patients. After 6 years in the ED, he made it look like it was as simple as putting on your pants in the morning.

Any advice you could give me would be greatly appreciated!

[lvariano]

Thank you for all the information you post here. I just started my Capstone for Nursing School and I'm in the ER. Came here looking for advice on assessing pts since it is done differently in the ER vs Med Surg. This has been very helpful in giving me direction to fine tuning my skills. thanks

[travelnursementor]

Best thing a New Grad can do post school is get a Fellowship in an ER or ICU and/or work in one for 2 years. Teaching hospitals and big trauma centers are the best. If you can stick it out 2 years you can do anything after. I feel bad for New grads that start at a small ERs. Its hit and miss on experience (limited exposure) and best quality of care. Big teaching hospitals not only have lots of Resident doctors that are eager to teach what they learned in school, they also have resources and staff development programs you can get involved in.

I jumped in head first, tore the bandaid off and started at a big city Level One trauma for 3 years. It took 8 weeks to not cry before I went in to work. after my first year, I could tell down to the week how long a new nurse had been working just looking at how they worked and how stressed, nervous, scared they were. Its normal. But the best thing about ER is we are a team. If you are at an ER that does not work as a team- Get Another Job! ICU direction if you want to do more involved care or really like floor type nursing, Grad and post grad level care (NP, PA), or even Jobs like Flight nurse (althought plenty go from ER/Trauma- just seems easier to go from ICU to ER for a bit then Flight than it is from ER to ICU for a bit and then flight. Only because we don't always get a change to look at results of patients etc.

Good luck

[AZQuik]

How does one know who needs a full head-to-toe and who just needs a focused assessment? For say, a hand laceration, I wouldn't really need to listen to heart and lung sounds. I guess it's just a judgement call, isn't it?[/quote']

First, someone will ALWAYS get past your radar. So everyone gets an interview 3-4 times. Do not neglect to ask someone's medical hx because it's already in the chart. Or allergies. Or medications (with dosage and last time taken). Or use a triage note as your assessment. 3-4 interviews yield a lot of info and can save your behind when you found a contraindication the md missed.

Second, altered mental status gets a head to toe. I've had people argue with me about this, again, altered mental status gets a head to toe. If you stay an ED nurse, you will remember reading this someday. Trust me. And yes, that includes the drunk in your ED for the 6th time this week on Thursday morning. I've had regular drunks with brain bleeds, in DKA, septic, and detoxing. They all got tuned and sent to the icu. Natural selection is not our job. It is the opposite. We keep people alive until told otherwise.

Then you need to know your systems. Things crash in a certain order, and that changes based on comorbidities and meds (a beta blocker can hide tachycardia on a pt, NSAIDs can hide a fever).

Every OT you see on orientation, you should come up with several possible differentials, and what is done to confirm/rule out. This is daunting at first, but will get easier the more pt's you see.

Good luck!

[Lunah, MSN, RN]

Second, altered mental status gets a head to toe. I've had people argue with me about this, again, altered mental status gets a head to toe. If you stay an ED nurse, you will remember reading this someday. Trust me. And yes, that includes the drunk in your ED for the 6th time this week on Thursday morning. I've had regular drunks with brain bleeds, in DKA, septic, and detoxing. They all got tuned and sent to the icu. Natural selection is not our job. It is the opposite. We keep people alive until told otherwise.

This is very wise advice. Never trust patient familiarity. I can recall a patient who was drunk and acting like his/her usual, but who had also fallen and had a head injury. The doc came *thisclose* to not doing a head CT, but changed his/her mind. Good thing — big ol' SDH with the beginnings of a midline shift, though the patient's neuro status was surprisingly intact — ambulated to the BRM and gave me a UA specimen just prior to CT, lol. Acute vs chronic. But yeah.

[pockunit, ADN, RN]

GO TO ALL CODES (if possible). These things have helped me in my short time in the ER so far, still lots to learn!

YESSSSSSS. You can learn SO MUCH from just standing in the corner and watching. What tests are they generally ordering? What is RT doing, what is the MD doing, what questions is s/he asking, where are the supplies, etc.

Assessment will come in time. You'll soon be able to tell if someone is sick/not sick just by talking to them when you take them back to the room. Sometimes the CC doesn't turn out to be the most important thing (witness new hypertension or diabetes that gets caught during the visit), and those will be important cases to pay attention to.

Also volunteer for any procedures you can, whether it's IVs, foleys, dressing changes, whatever. The more you do, the better you'll get.

[pockunit, ADN, RN]

YES! Loud babies are good babies. THE BEST BABIES.

[pockunit, ADN, RN]

altered mental status gets a head to toe. I've had people argue with me about this, again, altered mental status gets a head to toe. If you stay an ED nurse, you will remember reading this someday. Trust me. And yes, that includes the drunk in your ED for the 6th time this week on Thursday morning. I've had regular drunks with brain bleeds, in DKA, septic, and detoxing. They all got tuned and sent to the icu. Natural selection is not our job. It is the opposite. We keep people alive until told otherwise.

I would like to see this on the wall of every pt room in our ED. That AMS could be from a pressure ulcer someone missed, or the necrotic foot that the pt has been ignoring for the last month (you've all met this pt, I'm sure), or a UTI that no one caught.

I keep this advice and ABCDEFG- airway, breathing, circulation, don't ever forget glucose- in the back of my head for all AMS pts, regardless of their PMH. You just never know what the origin of that alteration is until you rule things out, and that starts with a good head-to-toe.

[Lunah, MSN, RN]

YES! Loud babies are good babies. THE BEST BABIES.

This should be painted over the doorway to every peds ED.

[amzyRN]

If they are breathing normally and have a good O2 sat with no cough, I feel comfortable saying their respiratory system is within normal limits. If their heart rate is regular they have no edema and they aren't there for chest pain, I feel comfortable charting WNL for cardiovascular system. If they are going to the bathroom normally and are A/O x4 I have no reason to doubt if they tell me they move their bowels normally, so I can chart WNL for GI. I try to focus on why they come in and go from there. Skin signs will tell you a lot too. A person that is pale, cool and diaphoretic usually needs a more careful assessment.

I am glad however that I did have floor experience first (not saying it is needed to be a great ER nurse) but I got to have lots of practice doing a full head to toe assessment and got to see the subtleties. With time, I'm sure this will come for the new grad in the ER too.