Any advice for a new ED nurse?

FancypantsRN · Jun 11, 2011

Wow, neat. I went from cardiac stepdown to ER as well. I love it so far. The biggest things I have learned so far (in about 4 months) are:

Focused assessments, this was the biggie for me. No need to do a head to toe for a finger lac. This sounds obvious, but it was difficult for me to grasp after almost 4 years of doing head to toe on everyone.

You don't have as much time to spend on one task like the floor. If you are getting multiple walk-ins and ambulances, you have to pick up the pace with IV starts, foleys, etc.

You can't always get them pretty prior to wheeling them upstairs. You still have to keep taking pt's and get the admits up as quickly as possible. If you have time to do the extra's then great, but don't beat yourself up if you can't. The flow is the very important.

Try to look up common things/gtts you may see in your ER on your own. You prob won't have time to look it up as it's happening (if it's an emergent patient).

Lastly, everything is STAT. As a floor nurse, this means drop everything and do that - you have a pt that is prob crashing. Again, obvious that it's not the case in the ER. That threw me a bit at first too.

That's all I got, sure others have more advice. Good luck in your new experience!

JDougRN, BSN, RN · Jun 11, 2011

Same scenario for me...and I still love the ED.!!! 1. Buy GOOD shoes. 2. At the grocery store, buy things that can be wolfed down without utensils. 3. Sharpen up your sense of humor and be prepared to be screamed at, cursed, spit at, threatened, physically abused, .....thanked, hugged, appreciated....and be there when people come in to this world, as well as go out. 4. Learn that you can't change the outcome of some things...but you can help people when they need it most.5. Learn to appreciate your coworkers. If they have gravitated to the ED, they probably have a sick, irreverant sense of humor, but I guarantee they aren't slackers...6. The floors and other units will NEVER get it. You will want to go up and THROTTLE a floor nurse for giving you tude about calling report for an admission...they will complain "I'm Too busy to take report at this time..." Only because they have NO CLUE what it is to be "BUSY".Do NOT let them make you feel like you are a bad nurse because you can't send the patient up puffed, fluffed, and all orders done. Same with Unit nurses. Sometimes the pt. needs to be transferred so they can get 1:1 or 1:2 care they can have in the ICU/CCU. Unit nurses may act like prima-donnas. The one time I had one of "THOSE" unit nurses float to me in the ED...by the end of the shift she was literally shell shocked. She looked at me and said " I HAD NO IDEA you guys have to deal with all of this...I will NEVER say anything bad about the ED again....." (One down...thousands to go!) 7. This is the MOST important thing you need to know about working the ED. You are ONE person, and you can only do what you can do. Under NO circumstances beat yourself up over what you can't do- you will be asked to do 1000 things at once. Stop. Take a breath. Pick the most important thing, and do that...go down the list from there. You are in for a WILD ride. Good luck, and let us know how you are adjusting. :)

Roy Fokker, BSN, RN · Jun 13, 2011

Hi Amy!

If I may:

* Prioritisation is THE key, and prioritisation is a little more complicated in the ED. Because in the ED, even your seemingly stable "admitted to Tele floor, waiting on orders" patient can (and in some cases WILL) crump...

So? Everyone gets watched - even your chronic alcoholics and frequent fliers and "incarceritis" patients...

* Some things can WAIT. Some things CAN'T. It's usually a toss up between medical necessity and creature comforts - draw your own conclusions.

* Just because they came by ambulance, doesn't mean they are a priority. Conversely, just because they walked in on their own power doesn't mean they aren't. Sounds like a cop-out but believe me, it isn't.

* I'm not sure what ED you'll be working in but in the ones I've worked - you're expected to be fairly independent. Which means, if the docs are busy and/or backed up, you're expected to initiate certain tests/studies in the interim (IV, blood work, x-rays, CTs etc.) Usually there are protocols in place. Even otherwise, good nursing judgment will save you headaches later on [e.g. pt. comes in short of breath. EKG is non-specific. Has risk factors for forming clots. You need to draw blood work and place IV - can't hurt to get an 18/20 g in the Right AC... just in case the Doc decides to rule out a PE.]

* You have a Doc present 24x7 - they are present to be consulted and used. It's what they're there for. Don't be shy running something by a Doc ("Hey, I know this isn't your patient but can I run something by you real quick?") Don't also be shy about asking a Doc what the plan is ("are you thinking the pain is PE or musculoskeletal?) - doing so will give you an idea of what to expect.

* Please, please, please DO NOT be afraid of asking for help if you're drowning. No ED nurse worth their salt will think any less of you - we've all been there before.

* The Golden Aim of ED nursing is "throughput" - admit or discharge. You've got to keep "moving the meat" - after all, how do you know that in the next 10 minutes a bus isn't going to overturn on the freeway and you'll be slammed with 30 patients?

* Brush up on the drips (meds, dosages, limits) used in the ED. And yes, the 5 Rights of med administration apply DOUBLE in the ED - patients will be in constant flux and you want to be doubly sure you're giving the right stuff to the right patient.

* Last but not least - don't leave your sense of humor [doesn't matter what kind] at home... you won't last a month without it! :)

Welcome to the "organised chaos" known as the ED!

cheers,

emtb2rn, BSN, RN, EMT-B · Jun 13, 2011

Agree with all of the above. Know your standing orders. Get things rolling before the doc sees the pt. Assess, line & lab. Expect the unexpected. Trust your instincts. Have fun.

shoegalRN, RN · Jun 14, 2011

Always try to keep your rooms filled! You don't want to get slammed with ambulance pts back to back.

I second for knowing your standing orders. If you get a pt from triage that is having chest pain, start running in your head what you are going to do for them as you are wheeling them back to the room (EKG, monitor, IV, O2, tubes to hold).

Try to get your patients worked up BEFORE the doctor sees them. You will need to anticipate what the doctor is going to order. So, by the time the doctor sees the pt, you would have had your labs drawn, IV inserted, your fluids going (if N/V, tachy, or hypotensive), have the pt hooked up to the monitor, and getting vitals q 30 minutes.

Also, it doesnt hurt if you go to the doctor and state "room 13 is actively vomiting, can you I give 4mg Zofran IV and a NS bolus?" Most docs are ok with this and will put the order in later. This was something I had to adjust to when coming from the unit. I was used to waiting on the doctor to order something instead of making recommendations.

Learn your RSI drugs. Get really familiar with the dosages as you will be the one drawing up these drugs and pushing them for intubation. On the floor, anesthesia do it. In the ER, the nurses will draw up the drugs and push them.

Also, know your most common drugs given in the ER, and also know your gtt's, especially for sedation.

Good luck!

mybrowneyedgirl, BSN, RN · Jun 14, 2011

Help out your fellow nurses any time you can and they will return the favors when you need it. Be an advocate for your patients. But- When docs choose to ignore pain, abnormal vitals, etc., document it in the chart so your hiney is covered come lawsuit time.

al7139, ASN, RN · Oct 17, 2011

Hi all,

Thanks for all your valuable advice! I have now been an official ED nurse for 4 months. I just came off orientation, and am "trying out my wings" so to speak. Luckily I am never alone and always have someone to go to for help if I need it. I am getting used to trusting my instincts and using our standing orders (i.e. chest pain get EKG, line, CBC, BMP, enzymes, monitor). Yesterday I was in fast track and I really had to "turn and burn" and anticipate what the PA's would order. I really, really love my job so far! I think I am the type of person who thrives on stress and chaos. I look forward to going to work now, and I see and learn new things every day, which means I am never bored. Plus, I am very proud to say I am an ER nurse when I am asked what I do.

Amy

RNFiona · Dec 12, 2011

Airway Breathing Circulation. And triple check meds and names. Siderails up..rememeber these things and you won't kill anyone

RNFiona · Dec 12, 2011

Always try to keep your rooms filled! You don't want to get slammed with ambulance pts back to back.
I second for knowing your standing orders. If you get a pt from triage that is having chest pain, start running in your head what you are going to do for them as you are wheeling them back to the room (EKG, monitor, IV, O2, tubes to hold).
Try to get your patients worked up BEFORE the doctor sees them. You will need to anticipate what the doctor is going to order. So, by the time the doctor sees the pt, you would have had your labs drawn, IV inserted, your fluids going (if N/V, tachy, or hypotensive), have the pt hooked up to the monitor, and getting vitals q 30 minutes.
Also, it doesnt hurt if you go to the doctor and state "room 13 is actively vomiting, can you I give 4mg Zofran IV and a NS bolus?" Most docs are ok with this and will put the order in later. This was something I had to adjust to when coming from the unit. I was used to waiting on the doctor to order something instead of making recommendations.
Learn your RSI drugs. Get really familiar with the dosages as you will be the one drawing up these drugs and pushing them for intubation. On the floor, anesthesia do it. In the ER, the nurses will draw up the drugs and push them.
Also, know your most common drugs given in the ER, and also know your gtt's, especially for sedation.
Good luck!

So basically you advocate " keeping your rooms filled" ? So basically you are saying don't turn over your patients too quickly to advoid getting too much work? Nice. Leaving the nurses who do the right thing to get slammed while you hold onto your patients to avoid getting new ones? That's lousy advice.

RNFiona · Dec 12, 2011

Originally Posted by shoegalRN

Always try to keep your rooms filled! You don't want to get slammed with ambulance pts back to back.

Terrible advice. You are an ER nurse. You should be able to handle volume. What would you do if the ED were hit with a mass casualty? Say, sorry I can't take another pt. My area is full?

emtb2rn, BSN, RN, EMT-B · Dec 12, 2011

RnFiona, I think what shoegalrn meant was to grab a pt from triage as soon as you clear a room. I tend to do the same thing.

She didn't say anything about not being able to handle volume. Just try not to invite simulpatients.

Conversely, i could accuse you of not taking pts out of triage because you're holding your room(s) for squads. See the twisted logic?