worked my very first ED shift,.assessment question..

  1. 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 though,..how thorough of an assessment is expected on these pt's? I'm used to doing a complete head to toe twice durring my shift on every pt..of course on the floor at night there are no Dr's,.so my assessment is the only assessment,..but in the ED the Dr is right there,..so how focused can I be and still feel as if I'm doing everything I need to be doing for these pt's,....for example 28 yr female w/belly pain,...any reason to listen to her lungs? Thnaks for some experienced advice,...I must say I think I'm going to love my new job,.the team work is amazing! Thanks everyone who has time to listen/advise
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  2. 17 Comments

  3. by   Altra
    It is different than the typical head-to-toe assessment of floor nursing.

    Personally, I listen to everyone's lungs - only takes a few seconds, and it's part of our standard nursing assessment in our documentation system.

    Other than that, my assessment can be very complaint-specific but thorough enough to cover all the possibilities of that complaint. Female belly pain: assess the abd itself, radiation of pain, also ask about urination, BMs, p.o. intake, pregnancy, and gyne symptoms.

    Welcome to the ER! :smilecoffeecup:
  4. by   Dixielee
    I have done both ICU and ER and you do have to approach the assessment differently. In an ICU, you generally have a patient for an entire 12 hour shift, maybe even days or weeks. In the ER, you HOPE you only have that patient for a few hours or less.

    While as an ICU nurse I wanted to see the patients Intake and output, in the ER, I am generally happy they are able to take PO fluids and urinate spontaneously. I am looking at the macro not the micro picture here.

    I do generally listen to lung sounds on most patients. You never know what you might find. I might not listen to them on minor lacerations, splinters in fingers, etc. A lot of that depends on how much time I have.

    ICU nurses are looking at every system in the body. Yes, they are all connected and depend on each other. If you do that in the ER, you will go crazy and never get anything accomplished.

    In the ER, some people will come in with a multitude of complaints. It seems like some have been saving them for years to drop in your lap all at once. You have to be able to focus on what brought them in that day and why.

    A good ER doc will also be able to address the immediate problem, and refer them to the family doc or specialist for the other 26 complaints they might have. You need to learn to focus on the main problem, but keep the other poosibilities in the back of your head.

    Now that I have told you to focus, I will tell a quick story where we focused too much. A 16 yr old female came to us from another ER after an MVC 3 days before. She had been seen at a local ER the day of the injury, given lortab and flexeril and sent home to rest with no obvious injuries.

    Her neck still hurt the next day so mom took her to her PCP, who told her she would be sore and to rest and take her meds.

    The day we got her, she presented at yet another ER with continued neck pain and mild disorientation. She was transfered to us (the trauma center)for further work up. She deterioriated before our eyes in a matter of hours and went from cooperative but drowsy, to comatose and intubated.

    It turns out she had bacterial meningitis. She was very sick, we all got treated with Cipro and I don't know if she made it or not, but was sent to ICU. The auto accident was a complete red herring and everybody missed it. So while I say focus on the problem they came in with, don't completely ignore other issues.
  5. by   RunnerRN
    When it comes to my assessments, I tend to be focused except on: old people, people recently d/c from hospital, babies, people that give you that "uh oh" gut feeling. Okay, so pretty much all of my patients!! Obviously you do an ABC assessment on everyone - I listen to lungs and check pulse on everyone. If a cc could be remotely cardiac (women with abd pain, people with upper back, jaw, neck pain, etc) I always ask about associated CP, SOB, diaphoresis etc.
    When people come in with long standing c/o or multiple c/o, I ask "what is the number 1 reason you came in today?" Then ask the number 2 reason. I also ask "what changed to bring you in today?" Both of these questions can help pinpoint if they just got tired of that mid belly pain every time they drink coffee, or if they started to get a pain in their chest along with their usual SOB.

    I hope this helps a little! ER charting is all about CYA
  6. by   RunnerRN
    Also, just keep your eyes open. You've gained excellent assessment skills through your ICU time. Someone on here tells a great story about a young guy with cc of shoulder pain. The RN walked into the room and the guy was pale, diaphoretic, and SOB. Ended up he was having an MI. Anytime someone just doesn't look "right" you need to listen to your gut! After you start to get comfortable in the ED, you'll recognize that rolling "uh oh" feeling you get in your belly when there is something subtlely wrong.
  7. by   Spidey's mom
    I have a hard time with not doing a complete assessment - and I still do one most of the time.

    I work in a rural ER where I have at most 3 patients in the ER and one in the triage room. I probably have the luxury of doing more of a general assessment.

    I'm just so afraid of missing something . .. .

    steph
  8. by   MULEKATE
    I currently work in the ER. I do a 5 minute assessment on all my pts. then do a focused assessment for their chief complaint. Remember that things are not always what they seem in the ER, people that come in with ABD pain especially women may be heart related and not actually be trouble in the abd. So always do at least at five minute assessment, then a focused assessment, then reasses. In the ER I work in it is policy that we round on our pts. every hour and vitals every two hours if they are stable. Hope this helps.
  9. by   EmerNurse
    I tend to do a quick 5 minute overall assessment. I include orientation, breath and bowel sounds, VS, pulses, quick overview. Then I focus on the primary complaint with a more thorough assessment. You'll be there all day if you do a full assessment on EACH patient. For very minor stuff - obvious sprained ankle, non-head lac, etc, I pretty much do the VS, focus on injured area, with the exception of old folks who have tons of co-morbids. Those I do the bigger quick assess on. Much like one of the posters above said.

    If I KNOW a patient is going to be going to ICU or the floor, I try to do a more thorough assessment at some point before they're formally admitted. I was a med-surg nurse before ER, so I go over most of the stuff I'd go over on the floor, and I will track I&O (though not hourly if I want to get anything else done!). In other words, I try to be able to give the receiving nurse a more thorough assessment report (especially skin for those oh-so-fun NH patients).

    Hope this made sense - welcome to the ER - it's the hardest job you'll ever love... and hate... and love.. and, well you get the picture.
  10. by   nursebrandie28
    I most of the time do the quick once over for small, injury specific complaints. Unless, like mentioned before the elderly, the babies and the "gut feelings," the more you work ER the more you will start learning what u NEED to do a full head to toe assessment and what not to...

    GOOD LUCK!!
  11. by   BrnEyedGirl
    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!!!!
  12. by   RunnerRN
    In response to your question above....my response isn't nursing school right, and I'll probably be flamed for it. But I feel that (in the ED) I am okay to accept meds pulled up by coworkers I trust. With the above meds, I'd definitely be more than a little uncomfortable though - a benzo, a narcotic? How did she dilute them? Did she even dilute them? My coworkers are awesome; they'll label drugs they pull up, and no one minds if you double check their dosages (so this one is Ativan 0.5 mg, this one is 4 of Zofran, right?).
    I don't see any problem with you saying "thank you for doing that, but I prefer to draw up my own meds until I'm a little more comfortable down here." I'm interested to see how everyone else does this.
  13. by   BrnEyedGirl
    Thanks Runner,.....I've been thinking alot about this (now after night 3),..if I had been w/one of my coworkers from my previous unit, I wouldn't have thought twice about giving the meds,...they are trying to help,.it did save me time,....several of us chatted about this last night,..a few rolled eyes,. but most agreed w/me,..I'm new to the ER,.don't know any of these people,.and several said there are nurses they don't like to have "help" from,...so I think all will be well,..for now at least those that know my feelings on the situation will not draw up meds if they don't have time to push them and sign them off themselves,..great plan and for the most part everyone is very supportive,...thanks again for the words of encouragment,..still gotta get over the not knowing everything about every pt,...all is good
  14. by   canoehead
    Nope, I don't give meds I haven't drawn up unless it's a major emergency. I draw up meds for coworkers, but I also give them. If there is a delay (couldn't get an IV) I tape the vial to the syringe and leave it with my coworker and tell them to let me know when they are ready and I'll be happy to push the med.

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