Real life in the ER vs. what we're taught in nursing school

neneRN, BSN, RN · Sep 6, 2005

Everything you mentioned happens everyday in my ER. Another one, drawing both sets of blood cultures at the same time with your IV start instead of 2 different sites/ 15 minutes apart.

BunnyBunnyBSNRN, ASN, BSN · Sep 6, 2005

I too graduated in May and as far as I've seen, school and the real world have so little in common I'm not sure they are from the same planet! :chuckle

S

MrsWampthang, BSN, RN · Sep 6, 2005

I graduated nursing school in May, and have been on the floor, still with my preceptor, at a big busy Level 1 trauma center for a couple months now. I'm interested to see how many things that were stressed as being so important in school are not done in "real life" at my ER. Wondered if these are practices that are common everywhere, and if there's any others that you've seen, where what you were taught just goes out the window in real life.
1. Wiping IV ports with alcohol swabs before accessing them. No one does this at my ER, no one that I've ever seen anyway, ever. Remember how many students failed skills validations because they forgot to wipe the port?
2. Carefully priming IV tubing, carefully holding up the ports on the tubing upside down so they wouldn't become filled with air...flicking out the bubbles in the tubing. Nope, in my ER, you squeeze the drip chamber, open the clamp and let it flow...period.
3. Carefully removing all bubbles from syringes. Remember hearing all the ball point pens tapping tapping tapping on the syringes during validation, trying to get out all those bubbles? No one really does that...maybe they're just better and faster at drawing up meds without getting bubbles in the first place?
4. Giving the pt. their call lights...I saw this on another forum here at allnurses.com. Is it a law, or something that the patients have to have the call light in reach? Ours are technically "in reach", they're draped over a hook on the wall behind the head of the bed, but NOBODY ever mentions to the patient that they have a call light!
5. Counting drops. We agonized over those calculations in school, but here at our ER, we have a saying, "there's fast, medium, slow, and TKO". That's about it, unless it's a med that has to go on a pump, of course. The doc's do order drips at particular rates, but in practice, everyone just "eyeballs" it.
6. Never ever touching the site after you've prepped for an IV. I see SO MANY nurses doing this! Many of them don't wear gloves, too. IV starts are so different in real life than what I learned in school. This is one that I'm actually trying to maintain the practices that I learned in school, I do wear gloves, and if I have to touch the site, at least I prep my gloved finger with the chlorhexidine (I think that's what we use anyway).
That's all I can think of right now. Anyone else?
VS

The only one that I know of that I didn't do when I worked in the ER is count drops. I guess I am from one of those other planets because I always do the other things the way I was taught in school and duing my preceptorship. I do admit that I only wear one glove when I start an IV, but I try not to touch the site after I've prepped it. Good luck in ER, hope your manager is better than mine. I recently resigned due to all the bull she allowed to go on in the department.

Pam

ARLadyRN · Sep 6, 2005

I graduated nursing school in May, and have been on the floor, still with my preceptor, at a big busy Level 1 trauma center for a couple months now. I'm interested to see how many things that were stressed as being so important in school are not done in "real life" at my ER. Wondered if these are practices that are common everywhere, and if there's any others that you've seen, where what you were taught just goes out the window in real life.
1. Wiping IV ports with alcohol swabs before accessing them. No one does this at my ER, no one that I've ever seen anyway, ever. Remember how many students failed skills validations because they forgot to wipe the port?
2. Carefully priming IV tubing, carefully holding up the ports on the tubing upside down so they wouldn't become filled with air...flicking out the bubbles in the tubing. Nope, in my ER, you squeeze the drip chamber, open the clamp and let it flow...period.
3. Carefully removing all bubbles from syringes. Remember hearing all the ball point pens tapping tapping tapping on the syringes during validation, trying to get out all those bubbles? No one really does that...maybe they're just better and faster at drawing up meds without getting bubbles in the first place?
4. Giving the pt. their call lights...I saw this on another forum here at allnurses.com. Is it a law, or something that the patients have to have the call light in reach? Ours are technically "in reach", they're draped over a hook on the wall behind the head of the bed, but NOBODY ever mentions to the patient that they have a call light!
5. Counting drops. We agonized over those calculations in school, but here at our ER, we have a saying, "there's fast, medium, slow, and TKO". That's about it, unless it's a med that has to go on a pump, of course. The doc's do order drips at particular rates, but in practice, everyone just "eyeballs" it.
6. Never ever touching the site after you've prepped for an IV. I see SO MANY nurses doing this! Many of them don't wear gloves, too. IV starts are so different in real life than what I learned in school. This is one that I'm actually trying to maintain the practices that I learned in school, I do wear gloves, and if I have to touch the site, at least I prep my gloved finger with the chlorhexidine (I think that's what we use anyway).
That's all I can think of right now. Anyone else?
VS

Boy, I agree with you. I have been with a relative in ER and the nurses didn't swab off the IV ports with alcohol nor did they dilute their IV pain meds or do another set of Vital signs for hours. They were good with their IV starts though. The call lights are sometimes not given. They were always caring though.

Luv2BAnurse · Sep 6, 2005

Reminds me of what an acquaintance of mine told me about where he works. He was taught to keep the work area clean during preparation as that is how things should be done, but no one ever does it. All those roaches just continue to crawl over the countertops and chop blocks at that restaurant. :chuckle

papawjohn · Sep 6, 2005

Hey Y'all

I admit right off the bat to being a cranky old fossil. Brought up with the strange idea that 'if you can't do something RIGHT, don't do it at all'--cause you make it harder for the person who comes along behind you and has to undo the part you screwed up before they can begin to put it together the right way.

That's how things were in the 40.s and 50's.

Obviously, you know that lots of things you learned in NrsgSchool were to give you the background needed to deal with the 'real world'. You weren't supposed to slavishly follow THOSE rules for you whole career. (I tell people, NrsgSchool is 90% INDOCTRINATION and 10% EDUCATION.)

But the validity of BloodCx's drawn from 1 site is less than 1/2 that of BloodCx's drawn from 2. (Not to mention that if the order said--"2sites", and you signed off that order & then sent speci's from 1 site---well, isn't that a lie?)

I look at it this way: If the carpenter who built your house--obviously knowing some shortcuts that do not compromise the quality as well as many that do compromise it--worked with the integrity you've describe, would you want to live in that house?

I find myself doing more 'work' (drawing Cx's twice, changing IV sites after 3 days) than the sloppy nurses that surround us do. But I find myself loving my job and satisfying myself infinitely more than the 2nd rate 'caregivers' you've described.

Take care in who you let lead you.

Ask yourself, 'what would Florence do?' You won't go wrong.

Grumble Grumble

Papaw John

**canoehead, BSN, RN** · Sep 6, 2005

1. Wiping IV ports with alcohol swabs before accessing them. Often doesn't happen but we have screw on connectors and it seems pointless when the alcohol can't reach even half of the surface area it should.

2. Carefully priming IV tubing Bubbles are not the death magnets you were taught in nursing school. You need a whole tubing full of air to hurt a healthy adult. However patients are very fearful of the air bubbles, and with sicker or smaller patients I tend to prime with greater care. I end up using less care when flushing more fluid means the patient loses some of the antibiotic dose to the trash can.

3. Carefully removing all bubbles from syringes. In nursing school we used to tap incessantly. Now one good whack against the med cart will usually suffice. I guess it's all in the technique. If you draw some air into the syringe along witht he med, and invert it you may find tiny bubbles will be absorbed into the big one too. Then just push the big air bubble out. But then again, a little air bubble is not the scourge we were taught in nursing school.

4. Giving the pt. their call lights Definitely a problem, and not just in your ER. In addition family members at the bedside tend to go and get the nurse (whereever she may be) to report a need rather than use the bell anyway.

5. Counting drops. After 10-15 IVs a day for ten years you will be able to eyeball too. Why not just work out the drip rate for 50, 100, 150, and 250 cc's an hour, put them on a piece of paper, and you won't need to worry about it. You also don't have to count for a full minute, 15 seconds is plenty. If your patient is so sick that they need an exact rate, then they need a pump.

6. Never ever touching the site after you've prepped for an IV. Many of them don't wear gloves, too. Prep your finger too- not OK in nursing school, but I never understood why not. Gloves- well the nurse is putting herself at risk, not the patient. Sometimes you HAVE to get an IV in a finger vein, or an infant, and gloveless is the choice you make.

carachel2 · Sep 6, 2005

I'm new in the ER too, but with about 3 months under my belt. I've seen what you've seen, adjusted some of my methods and still had many other areas where I refuse to decrease my level of care. All of my patients are handed a call bell button and told to press it instead of calling out "hey nurse." All of my IV sites are labeled with time, date, gauge and my initials. It helps the floor nurses out in terms of infection control. Of course, we are not a trauma center, so I know things might be different as far as that is concerned.

I see lots of veteran nurses continue with the same foley after multiple insert attempts on a female patient and I refuse to do that. I'll go get a new one, thank you. I prime my IV lines but I don't sweat every little bubble anymore.

PennyLane, RN · Sep 6, 2005

I see all of the above in my ER too. But nurses genenerally try not to touch a site after swabbing it. I will often swab my gloved finger if I really have to feel again. As for the call light, well, in my ER we do give the pts their call lights. For one, it gives them their TV control, and that will 1. make them happier, and 2. keep them occupied and out of our hair, so to speak, while we do our job taking care of our other patients. Often I'll forget to give them the call light, and the tech or the transporter will after I've left the room or if the pt is returned from CT.

And maybe this is just our ER, but if a doc orders NS at a rate rather than w/o or a bolus, most of us will put it on a pump. We're supposed to have one pump in each room...of course we're always a few short....but we have enough to go around.

Swabbing ports...some do, some don't. I'm trying to be better about this.

Here's one for you guys--flushing central lines with heparing flushes. I've been told, "they do that up on the floor, you don't have to worry about it here". ?????

EdieRN · Sep 6, 2005

I graduated nursing school in May, and have been on the floor, still with my preceptor, at a big busy Level 1 trauma center for a couple months now.
The new grads in my emergency dept had a 6 week orientation to emergency nursing. They are now working on their own and have picked up a lot of bad habits.

Happy-ER-RN, RN · Sep 8, 2005

My theory on swabbing ports is that if the pt. has been on the floor for a while that port has been to the bathroom with them several times and has has just been around longer to collect bacteria. In the ER it's only been there for a few hours at most. Now, if the patient is soaked in fecal material or the IV is per EMS and there are grass clippings and dirt mixed in with the tape, yeah, I'll give it a swab first.

But, I too thought all of those things were interesting at first. Everyone at my ER does all of those things as well. I still wear gloves when I start a line though and I always give them the call light, our call lights beep in to the secretary and she calls the appropriate person--if they just need a bed pan she automatically calls a tech and I don't even have to bother with it if I don't have time. It's wonderful.