worked my very first ED shift,.assessment question.. - page 2

Hi all! Worked my very first shift in the ED last night,..transfered from a cardiac/stepdown unit I had been on for over 7 years. Night went well from my point of view,..here's my question... Read More

  1. by   one_speed
    Quote from RN-Cardiac
    Thank you guys sooooo much,...just finished my 2nd shift,....ok,..another question,..it's seems as if I've "lucked out" in that I've joined the ER at a time of many changes,..including 30 new RN positions,..sooo there were like 8 nurses most of my overnight shift (13 beds on the trauma side where I was),..this means lots of team work and lots of "help",.good thing,...BUT,...maybe I'm being a bit anal,....making way to big of deal here,..had an order for 0.5 Ativan IV,..50 Demerol IV and 4 Zofran IV,..went in to start the IV,...another nurse walked in and handed me 3 syringes "here's your Ativan, Demerol and Zofran" she laid them on the bedside table and walked out,....ok,.she saved me a trip to the Accudose etc,..I feel really wired about pushing meds I didn't draw up!!!,or even see drawn up...I don't know any of these people,...should I just get over this???
    Thanks sooo much for your encouragement everyone,..so far I really do like the ER!!!!

    Welcome to the dark side (the ER of course) !

    I'm sure that everyone here will agree that the ER is one of the most exhilerating yet exhausting places to practice nursing. Of course, this is the reason that most of work here and would choose nowhere else to be at work. The chief reason behind this is the variety we see each and every day / night.

    You never know who is next or what is actually going on with them (we all know that the stated complaint isn't always the only or chief problem many of these people have).

    Rather than get into a discussion of the mnerits of specific assessment processes I want to bring up a couple of points.

    I have found that a large portion of our initial ER assessment is the directed history (OPQRST, mechansim of injury, etc.) surrounding the initial complaint. Red flags often start to pop up with people with multiple symptoms that they associate with the initial complaint. You know the persistant neck pain, head ache, diziness three days post MVC, ineffective analgesic / NSAID use, (what caused the initial MVC ?) etc. The broken hip due to fall... why did they fall ?...etc. Acting as an investigator to draw out the details much of our initial role in the ER. The ER doc can proceed withg their more focused assessment and diagnostics to pinpoint the problem.

    Once the MD has an idea of the problem (plus differential diagnoses of course) my primary function is to perform interventions within the scope of our practice, and assess the effectiveness of those interventions. Eventually a diagnosis can be made by ruling out problems, and the pateint will be discharged feeling better or admitted for further investigation, observation, and interventions.

    The detailed nursing assessment is critical as we progress as we can flag problems, identify ineffective treatments, etc. the Physician / ER Nurse relationship is a closely knit one, and a strong sense of teamwork is evident in good ER's.

    On that note, rises the next issue of teamwork. Sometimes the help causes more problems than good. "We'll help bring patients back, assess them then leave", "We'll help move you patients into the hallway to allow the next patient to come in", "We'll take the orders and enter them for you... then an hour later the doc is at your heels asking why patient such and such (who you haven't laid eyes on) hasn't gone for xray (oh, the order was never submitted).... okay enough of the rant.

    In my ER we work under a mixed system (our own bed assignements, but teamwork and helping out one another of course). Don't be afraid to tell other co-workers that their "help" is not helping, and stand up for yourself. Especially as a new ER nurse, things may not move as fast as when you've been there for 5 years.

    If this happens again, how about they start the IV, you go get your drugs mixed how you like them so that you can administer them (Eveybody seems to like to push so many iv drugs instead of infuse them), then you know when you go back to assess the results of the intervention you can let the MD know in detail what happened. You form a closer relationship with the patient, and can intervene on their behalf if needed (ie. stronger pain management, move to a trauma room for more detailed assessment.

    The situation you described wasn't very detailed, was it a resuscitation case or trauma (++ team work), or sub acute care. Don't accept that you can't bring your years of experience to the table just because of an "it's how things work around here" attitude.

    It gets my goat that students and new grads will often be hired to the ER and will get the same RN as their "orientation preceptor" becasue they already have a relationship. So many bad habits get passed on in this manor (in my opinion). RN's that transfer in from other floors / hospitals often get the bums rush because they tend not to do things the same way. Bring all the experience you can, learn from as many people as you can, and move ahead.

    Welcome to the game.

    Cheers, Ian
  2. by   mmutk
    I do a symptom based assessment, as far as the other areas of the body I do a simple "from the doorway" assessment. If it don't hurt ya I don't need to focus on it.

    Trauma patients being diffrent (complete TNCC head-to-toe x2)
  3. by   Jennifer, RN
    I also worked on a tele unit before I transferred to the ER, have been er nursing for almost 2 years and would never go back to floor nursing!
    I was also used to full body assessments, but quickly learned that in order to keep up to the pace in the er, I had to focus on cc. There are time when a complete head to toe assessment is necessary, though. Septic or very ill pts need complete assessments, sick peds pts and most elderly also. If I am bolusing fluids, I will always listen to lungs and heart tones.
    On the other topic, I do not give meds other people have drawn up unless I am very familiar with that person. Even then, I will usually ask them to give the meds unless it is a very ill or injured pt. I never draw meds up and expect another nurse to give them. If I get meds for another nurse, I will get the vials and syringes and bring them to the nurse and either draw them up in her presence or give them to her to draw up herself. I know that at the end of my shift, I can get pretty tired and less focused, so I bet other nurses feel the same, and I would hate to make a med error because of another nurses error.
  4. by   LeesieBug
    The "too many cooks in the kitchen" thing drove me NUTS when I started (as a new grad,no less). Often those trying to help me caused me more stress, especially if things were done too soon (like calling CT to get pt while I was still sweating through a difficult IV stick), or had already been done and I wasted time preparing for something that had already been done. It also interfered with my learning how to hit a groove and become organized.

    I wound up just asking the charge to have everyone NOT to jump in to help me unless I asked, for a while. I busted my hump but it helped me learn my prioritization and organization, and I always knew who was doing what and when...because I asked them to and they consented!

    Now that I have been there a little while, I am fine with my co-workers jumping in...we all know how one another work.
  5. by   Victoriakem
    Quote from RN-Cardiac
    Thank you guys sooooo much,...just finished my 2nd shift,....ok,..another question,..it's seems as if I've "lucked out" in that I've joined the ER at a time of many changes,..including 30 new RN positions,..sooo there were like 8 nurses most of my overnight shift (13 beds on the trauma side where I was),..this means lots of team work and lots of "help",.good thing,...BUT,...maybe I'm being a bit anal,....making way to big of deal here,..had an order for 0.5 Ativan IV,..50 Demerol IV and 4 Zofran IV,..went in to start the IV,...another nurse walked in and handed me 3 syringes "here's your Ativan, Demerol and Zofran" she laid them on the bedside table and walked out,....ok,.she saved me a trip to the Accudose etc,..I feel really wired about pushing meds I didn't draw up!!!,or even see drawn up...I don't know any of these people,...should I just get over this???
    Thanks sooo much for your encouragement everyone,..so far I really do like the ER!!!!
    I NEVER give any meds I didn't draw up myself, with the rare exception of working with someone I have known for a long time & completely trust. It's just not safe. And I'm the Safety nurse in my ED. As far as the assessment. coming from a Med-Surg background & used to doing a head to toe, just focus in on the main problem & work out from there. If the patient gets admitted very soon after they arrive in the ED & go up to the floor right away,(a rare occurance but can happen) I don't always get the full assessment done. Plus if a patient's wheezes are audible & bilateral, there's no use listening to them with a stethoscope.

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