Cardiac to ED

Crocuta, RN · Jun 27, 2009

Congratulations on your move!

I find the idea of not doing head to toe assessments an amusing one. Consider that when you are an ER nurse, you get a patient without a neat and tidy diagnosis. You'll get the patient without having any idea what's wrong. A vauge and not very helpful complaint sometimes, other times, a complaint that doesn't really have much to do with the real reason they've presented. We do some of the fastest and most critical head to toe assessments of any department. You have a very short time to get a total assessment so you can start running your possible differentials in your head to figure out what direction you'll be going in - is it an MI? A dissection? GERD? Does that trauma patient have any other ominous findings that no one else sees because they're focused on the mangled foot?

You'll see many of the same conditions that you see on the floor, but you get them when they're still scary and unstable and undiagnosed. It rocks.

Good luck!

Editorial Team / Moderator · Jun 27, 2009

I find the idea of not doing head to toe assessments an amusing one.

Yeah, I'm trying to wrap my head around that, and failing. Our system policy is that anyone with an ESI level of III or less gets a head-to-toe, which can sometimes be excessive, but is often necessary. And no feeding people, either? "Sorry, ma'am, I know you have diabetes and your glucose is dropping, but we don't feed people here." LOL! Virgo_RN, welcome to ED-land! I think you'll find that yes, you will feed people, and you will WANT to do head-to-toe assessments on some of your patients. You can always expect the unexpected in the ED. Good times.

Virgo_RN, BSN, RN · Jun 27, 2009

So you guys are required to perform and document a complete head to toe assessment on every patient? That's a new one to me, because all I ever get from the ED when I admit a patient is a handwritten flow sheet that has no head to toe assessment anywhere on it. I would imagine that there would be situations where a rapid head to toe would be warranted, but my impression is that in general your assessments are rapid and focused, and you do not have the same documentation requirements that exist on the floor.

As far as feeding people, I was referring to meal trays being served. Obviously a diabetic who is on insulin or oral hypoglycemics would need to eat something if they are in the ED for any length of time. Our ED will even get someone a sandwich or something if they've been there all day and there is no reason for them to be NPO, even if they're not diabetic. Am I incorrect? Are meal trays commonly served in the ED?

Editorial Team / Moderator · Jun 27, 2009

Yes, we commonly serve meal trays to our ED patients if it's meal time, they're able to eat (no tests pending, NPO status, belly pain, nausea, that kind of thing), and if they're hungry and ask for food. We'll also occasionally feed family members if they're nice.

And yes, we are required to perform and document a complete head-to-toe assessment on patients who are meet certain acuity criteria. We use the ESI triage system in our ED. As I said in my previous post, Level III, Level II, or Level I all get head-to-toe assessments.

We're also required to do med recs. At least we're now doing them electronically, which is a blessing.

When do you start? Have you shadowed anyone in the ED? That might give you a good idea of what to expect.

Virgo_RN, BSN, RN · Jun 27, 2009

Wow, well they don't do meal trays in our ED, and the head to toe assessments are not required for every patient, every shift, like on the floor. Their assessments are focused on the primary complaint and whatever else comes up during the visit. I suppose head to toes would be warranted for traumas and certain other conditions, but if someone comes in with SOB or CP, they're not turning them over to do a skin assessment and check for decubs. That gets done by the admitting nurse on the floor. The ED does not do med recs either. If the patient is to be admitted, they have a medication worksheet they fill out, which usually just consists of the names of the meds the patient takes, and rarely if ever has the dosage or frequency on it. I recall a while back there were some ED nurses doing the med recs, but I haven't had a patient come up from the ED with a med rec done in months.

On the floor we have computerized charting and have to complete and document a full systems assessment (head to toe), a pain assessment, an IV assessment, a nursing narrative, an overview of their hospital stay, and of course their routine vitals/medications/nursing interventions. In the ED, they use a flowsheet and document IV starts, medications, focused assessments, and narrative on that flowsheet. It's quite different.

I don't start for a few weeks yet, and I did not have an opportunity to job shadow. It's against our rules to float an RN down there (they're not part of our "pod" or something), so I haven't been floated there either. It's an internal transfer, so it's handled a bit differently than a regular job interview/hire situation. I have spoken with some other floor nurses who transferred down there and love it. Our unit has had many nurses transfer there, and they never come back. Fortunately we do have a union contract that has conditions for transfers, so if it's not a good fit, either for me or for the established ED staff, I can have my old job back.

It's a Level II trauma center, BTW.

sandypalma · Jun 27, 2009

as far as trays commonly serve..no.. but if we have a pt thats been here all day we can order him or her a hot tray..at least over here in our er..

rnbikermama71 · Jun 28, 2009

I LOVE BEING AN ED NURSE!!!! I HAVE BEEN ONE FOR THREE YEARS. Advice: get your BLS, ACLS, PALS, TNCC AND SO ON! Good luck!

Virgo_RN, BSN, RN · Jun 28, 2009

I LOVE BEING AN ED NURSE!!!! I HAVE BEEN ONE FOR THREE YEARS. Advice: get your BLS, ACLS, PALS, TNCC AND SO ON! Good luck!

Already have ACLS, required to work in cardiac.

What do you love about the ED?

Editorial Team / Moderator · Jun 29, 2009

I love the variety of patients and complaints -- I'm always learning something new, which really appeals to me.

Virgo, it sounds like your ED will be a great place to work!! Good luck -- let us know how it goes. :) How exciting!! I definitely agree with the other poster -- take TNCC as soon as you can, since you'll be in a Level II.

RoyalNurse · Jun 29, 2009

Hi Virgo,

I work in a CVICU, and I'm thinking of transferring to the ED as well! I have a friend that works "down there", she has a lot of complaints, but I can tell she really enjoys the fast pace and adrenaline.

I'd love it if you could update us on how your ED adventure is going, you could even email me (under my profile name).

bjaeram · Jun 29, 2009

I have to say I love the ER and can't imagine doing anything different but you will find your own complaints. The grass isn't always greener. Some things will be better and some worse. Here are a few ideas.

Pros

-different patients, complaints every day. You never know what you will get from one minute to the next. You can have a cardiac, a pediatric, and a psych all at the same time. You learn a lot and you don't get bored.

-yes we have less paperwork then you do. We are required to do med recs and the way I understand it all ER's are now.

-we don't document head to toes all on patients but we do on traumas and very sick medicals.

-We have to be investigators. Pts don't come with a diagnosis. Sometimes we have no information other then someone found them like this. We may not know names, past history, or even the reason they are there

-If you have a patient you don't like you only have them for a short time

-Huge adreneline rush when you get a nasty trauma and great satisfaction when you save them

_You always have a doctor in the ER if you get into trouble they are a shout away.

Cons

-You are a jack of all trades and know a little about everything but not a lot about anything.

- You can go from busy to busier in a second. You can't turn down a patient because your rooms are full or you have a certain number of patients. They keep coming.

-All the floors in the hospital especially the ICU think you are dumb and incompetent because you haven't done a head to toe, you don't know breath sounds on your broken foot, the patients aren't all cleaned up and in a nice little package when you are done

-You don't get to see what happens to patients. You stabalize them and ship them off. You often don't know if they got better or worse

-You see patients and families at their worst. They are stressed an scared and take it out on you.

-You get tons of non emergencies

-Yes we feed people and they expect it even if we don't have routine meal times. It's actually more of a pain in the ER to feed patiets because of this. We have to call dietary and find a tech to go get the tray. It's not automatic like on the floor.