Certifications for an ER nurse

One1, BSN, RN · Sep 12, 2012

We need BLS, ACLS, PALS, TNCC and ENPC to work in the ED. CEN at some point is desired but optional.

Robublind · Sep 13, 2012

Not all ED positions require TNCC or ENPC. In our area you only need them if you are working in a trauma center. That being said TNCC and ENPC are great classes to take. They teach you how to do a systematic assessment on a trauma pt.

lyttlemomma · Sep 13, 2012

Thanks so much guys!

Larry77, RN · Sep 13, 2012

You will get a lot more from TNCC and ENPC once you've seen a few traumas and a few very sick kiddos. Anymore, at least in my area, you have to have some sort of prehosp or ED experience (ED tech) to get hired as a new grad in the ED. I would get your PALS and then work on networking with someone from your ED--some times it's who you know.

When you do get into the ED your psych experience will help tremendously...good luck!

lyttlemomma · Sep 13, 2012

Thanks so much for all of the suggestions everyone!!! :)

brainkandy87 · Sep 14, 2012

I started in ER with only BLS and ACLS and I did okay, but I learned as much as I could from other nurses. So by the time TNCC rolled around, I already knew most of what was covered, e.g. spinal cord injuries and precuations, shock, et al. I used to think you should work in the ER for about six months before taking TNCC, but my opinion of that has changed greatly. I honestly think TNCC should be something that is obtained as soon as possible in the ER, as I see a LOT of inexperienced nurses not doing basic things like c-collar for a neck injury or not adequately monitoring pressures for a pt in shock or not infusing fluids as they should be on trauma pts or putting in 22g IV's (I took over an SCI pt the other day that had a 24g IV only) or blah blah.

I have just grown to be anal, because I've seen some nurses do things that just scare the crap out of me and I don't want patients dying or having poor outcomes because we didn't do things the right way. Anywho, sorry to deviate from the original topic.

Hope you join the ER crew! It's always a fun place to work.

VICEDRN, BSN, RN · Sep 17, 2012

I started in ER with only BLS and ACLS and I did okay, but I learned as much as I could from other nurses. So by the time TNCC rolled around, I already knew most of what was covered, e.g. spinal cord injuries and precuations, shock, et al. I used to think you should work in the ER for about six months before taking TNCC, but my opinion of that has changed greatly. I honestly think TNCC should be something that is obtained as soon as possible in the ER, as I see a LOT of inexperienced nurses not doing basic things like c-collar for a neck injury or not adequately monitoring pressures for a pt in shock or not infusing fluids as they should be on trauma pts or putting in 22g IV's (I took over an SCI pt the other day that had a 24g IV only) or blah blah.k.

You're big on the IVs lately, brainkandy but I gotta say, I'm not feeling you. Basically (as I read the literature), there is little actual difference between an 18 and 22 when infusing a bolus over the course of an hour. For patients requiring rapid fluid resuscitation, a central line or a cordus is more appropriate and really quite frankly, necessary for large fluid volume replacement. If the ER MD starts pi$$ing and moaning about the gauge, I roll my eyes.

If the patient has a 22g, its because there was no other gauge that the 89 year old trauma or chronic dialyzer would tolerate. Drill em or get a central line in them but don't whine to me that they need a different gauge.

AND...feet are dirty lines, ICU will simply remove them and they can cause a great deal of fluid pooling in a patient that has renal insult which can lead to necrosis. (Seen that before in my husband's ICU where his coworkers accosted me about foot lines.)

eatmysoxRN, ASN, RN · Sep 17, 2012

Speaking of IV gauges, have you guys looked at the packaging of IVs? Those things can push fluid out quickly enough to blow a PIV. I know large gauges are preferred, but geez, if a 22 is all they can get, I'm happy. It's better then no access and it can accommodate a bolus.

TheSquire, DNP, APRN, NP · Sep 18, 2012

You're big on the IVs lately, brainkandy but I gotta say, I'm not feeling you. Basically (as I read the literature), there is little actual difference between an 18 and 22 when infusing a bolus over the course of an hour. For patients requiring rapid fluid resuscitation, a central line or a cordus is more appropriate and really quite frankly, necessary for large fluid volume replacement. If the ER MD starts pi$$ing and moaning about the gauge, I roll my eyes.
If the patient has a 22g, its because there was no other gauge that the 89 year old trauma or chronic dialyzer would tolerate. Drill em or get a central line in them but don't whine to me that they need a different gauge.

While I disagree with brainkandy87's "Large bore all the time!" stance, I also disagree that large bore's aren't appropriate emergently for large volume fluid resussitation. I can and have pushed 3L/hr through an 18g with a pressure infuser into a septic patient, and two large bores actually allow more flow than a central line. I mean, I'll take any access over no access, but if my patients pressure is so crappy that I've pulled the line off the pump and put the bag in a pressure infuser, I want at least a 20g, if not better. As you mention, though, with some patients you may not have the veins to do the large bore emergently until the first couple liters go in.

As for IO, you're free to convince my hospital to train the ED nurses on IO insertion so we don't have to wait for the docs, who never want to start them...

hiddencatRN, BSN, RN · Sep 18, 2012

You're big on the IVs lately, brainkandy but I gotta say, I'm not feeling you. Basically (as I read the literature), there is little actual difference between an 18 and 22 when infusing a bolus over the course of an hour. For patients requiring rapid fluid resuscitation, a central line or a cordus is more appropriate and really quite frankly, necessary for large fluid volume replacement. If the ER MD starts pi$$ing and moaning about the gauge, I roll my eyes.
If the patient has a 22g, its because there was no other gauge that the 89 year old trauma or chronic dialyzer would tolerate. Drill em or get a central line in them but don't whine to me that they need a different gauge.
AND...feet are dirty lines, ICU will simply remove them and they can cause a great deal of fluid pooling in a patient that has renal insult which can lead to necrosis. (Seen that before in my husband's ICU where his coworkers accosted me about foot lines.)

I work in peds, so I think I'm more tolerant of smaller gauges too (on some patients, a 22 g IS "large bore"). Better to get quick access initially, than to blow a couple attempts at an ambitious gauge. You can always add a second line (and likely would anyway if the patient is sick) after a few meds and some fluid are on board. Plus, we give blood through 24 gauge IVs all the time with no issue, so for non-code/trauma blood needs, I do not get the drama over "only" having a 22 gauge in or whatever.

Larger gauge is always nice but I'd never suggest someone is a bad/dumb/lazy nurse because a patient may have had poor veins and they opted for access over multiple pokes with an 18g.

brainkandy87 · Sep 19, 2012

You're big on the IVs lately, brainkandy but I gotta say, I'm not feeling you. Basically (as I read the literature), there is little actual difference between an 18 and 22 when infusing a bolus over the course of an hour. For patients requiring rapid fluid resuscitation, a central line or a cordus is more appropriate and really quite frankly, necessary for large fluid volume replacement. If the ER MD starts pi$$ing and moaning about the gauge, I roll my eyes.
If the patient has a 22g, its because there was no other gauge that the 89 year old trauma or chronic dialyzer would tolerate. Drill em or get a central line in them but don't whine to me that they need a different gauge.
AND...feet are dirty lines, ICU will simply remove them and they can cause a great deal of fluid pooling in a patient that has renal insult which can lead to necrosis. (Seen that before in my husband's ICU where his coworkers accosted me about foot lines.)

Well if you want to look at the numbers, you can put 600 ml/hr through a 24g. Does that mean we put 24g's in every pt that isn't going to be getting rapid infusion? Nope. Hell, most ER nurses would slap someone for putting in a 24g IV on any adult. Do 22g IV's serve a purpose? Absolutely. They're great for peds and LOL's that just need something to push meds. Personally, I have a standard of care that is consistent for everyone, trauma or not, that they always get an 18-20g IV. I don't mess around putting 22g's in people because "it hurts less." A needle is a needle.

Now, considering we are talking trauma patients, yes, everyone gets an 18g IV. Heck, TNCC teaches you to put in two large bore IV's on trauma pts. You can never, ever go wrong with an 18g IV. I'm more of the thought that I'd rather overprepare than underprepare. If you overprepare, you have your crap ready when it hits the fan. If you underprepare, you end up screwed every time. By putting in an 18g IV on EVERY trauma pt, I don't have to worry about needing a bigger IV if and when someone takes a sudden turn for the worse. I've been in that situation where I didn't plan ahead and put a 22g in someone. Guess what? I screwed myself.