New RN in ER: things I don't even know that I don't know!

  1. I've got 3 more days with my preceptor, and I KNOW the things that I need work on...getting faster, getting better at IVs, finding the veins quicker, asking the right questions to zero in on the pt's issues, ordering all the right labs & xrays, etc. Those are just things I know already, but need to get better at. Then there are the med issues...trying to remember what the dilutions and time to infuse or push for the usual meds...most antibiotics you're safe if you use 100ml NS over 30 minutes, but then there's Vanc, and Levaquin...but those are the things that I KNOW that I don't know, so I'll keep looking them up each time until I know them by heart.

    My concern is all those things that I dont' even know that I don't know, ya know? Like last week several nurses were running around looking for filter tubing to hang some mannitol...well, I remember reading somewhere about mannitol used for ICP, but I don't remember that it needed a filter. So if it had been my pt, I wouldn't even have KNOWN that a filter was an issue. I would have looked it up, since I"d never given it, but I would have looked only under "rate of administration" and "dilution", I don't have time to read the entire section on every single drug that I look up.

    So I just worry about all those other things that I don't even know that I don't know. You can't learn everything during orientation, and there's SO MANY things we didn't get the chance to do during orientation...

    Getting nervous about being on my own...guess you can tell!

    VS
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  2. 11 Comments

  3. by   Dixielee
    I have found my palm pilot to be an invaluable resource. Don't be too hard on yourself about having to look things up. I have epocrates and Davis drug guide as well as Merck manual and some drip calculation programs on my PDA.

    Make yourself a notebook, I like the little ones you can get at walmart, with the black and white hard cover and no spiral,and fit in your pocket...it is tougher, the pages are stronger and last longer. Make a page for common antibiotics and how you mix them and how fast to infuse them. Have a page for handy phone numbers like x-ray, CT, lab, pharmacy, how to call chaplain, security, overhead page, etc. I also keep the local taxi, animal control, poison control, main hospital number, etc.

    You can make a page for quick lab results, and other common things you run up against. As you find yourself asking questions or looking something up...write it down. Keep it brief. Utilize your resources.

    Read nursing journals, seek out classes, take all the ER related classes you can, ACLS, PALS, TNCC, ENPC, etc. Get really comfortable with cardiac meds, symptoms and treatment.

    Remember your ABC's....airway, breathing, circulation. If you can make sure your patients have all of the above, then you can relax and do what you need to do. Heart patients can change quickly, so know how to care for them, know your rhythms and which can kill quickly and how to treat. Be able to recognize SVT, VT, a-fib, tachy and brady, and 2nd degree heart block. Those are the ones that can kill, most of the others can wait.

    Many new situations will come your way, just be open to learning. Ask your collegues to let you know if something different and interesting comes in and go check it out. In a trauma or code, if you have the opportunity to stand in the corner and observe, do so, or station your self by the cart and hand out meds, but don't run around trying to do too much, because you will only get confused. Pick one thing you are comfortable with and do it, and you will learn just from being in the room. Ask questions afterward as well.

    I am never too busy to answer legitimate questions. If you are sincerely trying to learn, there will be those who will help you do so. I am never afraid of the new nurses who are asking questions, it is the ones who think they know it all and never ask questions that I am afraid to work with.

    Time will teach you a lot, just keep your eyes and your ears and your mind open. Good luck.
  4. by   ClaireMacl
    OMG! Things are different in the US. I'm a senior ED nurse in the UK, been there for three years and I can't assess for xray, I can ask for someone who has done the course (someone who has been there for 3+ years) to order one, but I can't imagine having started in the ED and ordering!

    Of course, I'll be on the course very soon and now am very aware of who needs it and who doesn't, but even after the course, we are only allowed to order limb xrays, for possible fractures etc, we are not allowed to order CXR's, although generally, we ask a doc to get it well before they are seen on our clinical findings.

    I can't believe you have so much responsibility as a new ED nurse, are you senior or qualified for a long time?

    Btw, we never use a filter for Mannitol here, we just monitor closely after commencing.

    As for worrying about checking with meds, to be honest, even if you are qualified for 15 years, if you aren't giving it daily, check it with the IV admin guide of your hospital! I check soooo many things, afterall, two minutes checking versus licence, better to be safe than sorry and these drugs are not so critical that you need worry about the delay.

    Take it easy, it sounds like you have been put in the deep end to me, perhaps its just the UK-US differences, but I'd hate to hear you burn out. Here, our nurses have about 6 months before we expect them to be able to fully and competently assess every patient on admission without asking questions... infact, if they don't ask questions, we think they are dodgy!

    Best of luck and try to enjoy it and not become too overwhelmed!

    Cx
  5. by   KatieBell
    Things are really different it seems between the US and the UK. I worked with a UK doc and she was amazed that as a nurse, I order up a Head CT (based on the patient fitting the protocol) for suspected CVA. She was also surprised to learn that I go to CT with trauma patients, intubated, on drips and manage them without the physician (With the physicians orders and pager of course! to titrate the drips etc, but not with the actual body of the physician...)...

    But she also worked in a small hospital, where CTs, and big trauma weren't all that common according to her. In my ED we run on protocols, so most of the time, all the basic labs and tests are ordered before the physician gets in to see the patient. The physician then decides if some other tests might be needed.

    You'll get it and you will keep coming across things you don't know. As you get to know the other nurses keep in mind who used to work where. This info is invaluable in specific situation. Former Peds nurses are usually very good at placing IVS in squirmy kids, and former Neuro nurses usually don't forget how to zero the ventric or about Mannitol. And, we usually like to be asked about something we know about! (It makes us feel smart...hee hee)

    Best Wishes, keep asking questions, and keep learning.
  6. by   hrtprncss
    hello....just a quick note on mannitol, we've all seen mannitol on glass bottles that's been stored in the pyxis way too long crystallize like ice, this was when we used to have to mix our mannitol ourselves...now we don't have to it comes premixed from pharmacy....but here's a link oh guidelines when to use filters with whatever medications...it's just a quick guideline with reasons as to why...

    http://www.utmb.edu/rxhome/Operations/Filtrations.htm


    hrtprncss
  7. by   babynurselsa
    Always know where a good CURRENT med book is. Do not be afraid to take a minute to look a med up before you give it. 9+ years later I still do it daily. I will not give an unfamiliar med without making sure I am giving it appropriately.
    Another good resource is the trauma checkmate pocket guide.
    Just hang in there, continue to ask questions. When I first started ER my manager said it takes a good solid year to get comfortable. By this time you have gotton good experience on all of those seasonal things plus the "everyday" stuff.
    Hang in there.
  8. by   SUNNSHINE 54
    Just remember we were all new at one time or another. Don't be afraid to ask question, and read your journals. I have been doing this 30+ years and I don't know it all. I keep a current drug book in the department, keep up with the current journals and I ask question of the doctors( a good resourse). Attend education classes when you can. Stay with it and you will do just fine. Good luck.
  9. by   carachel2
    I'll tell you what all the other nurses keep telling me when I ask questions and they say "it's the nurses who DON'T ask" that they don't like working with. I've had many a bad day where I feel like a total moron (see post below) and then some good days where i knew what I was doing and what was going on (those would be the days when I have my cardiac patients lined up in a row, LOL)

    Hang in there, keep asking questions and write things down in a little flip book thing.
  10. by   cheripa
    I'm a new grad in an ER. I carry a little black book and write tons of things in it. In my department, the nurses are very helpful. My biggest thing right now is getting organized. I'm having a problem with putting the knowledge into clinical practice. It's a hard transision from student to RN, but I jumped in feet first into the ED, so I expect to be overwhelmed a lot. I bought a PDA and I'm still trying to get things loaded on it so that I have good resources in one spot. Hand in there! It sounds like a lot of the new grads that started in the ED are all having the same challenges. It's nice to know that I'm not the only one!!
    Keep a good atittude! Don't let the overwhelming experience kill your confidence.
  11. by   Havin' A Party!
    Good post, Dixie!

    Thanks.
  12. by   Adenosine_Addict
    I precept many people to the ER. Unfortunately, what you will find is that the more you know, the more you realize how much you don't know. Learn the basics and treat the ABCs. Everything else is gravy.

    Who cares how long Rocephin takes to go in? If you absolutely must start IV ABX immediately with no reference (a scenario I can't imagine even with Zosyn) start it over an hour and look it up.

    Learn to know your resources. That is where you make your money in the ER. I don't remember every differential between every disease, but I can look it up. Also remember the big stuff is life saving. The rest can wait. If I had one single pearl for ER it'd be ...."learn the difference between sick and not sick"...and what is the most important thing RIGHT NOW....unfortunately, that doesn't require a checklist...it requires time.
  13. by   NYNewGrad
    Great thread.

    Im a new grad (BSN) and was offered ER. The thought of working there both excites and scares me!

    The tips offered here are great.

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