Currently on orientation at a level 1 trauma ER,help!

lainaa · Dec 14, 2017

Heyyy other new ED nurse. I'm at week 7 too and it's pretty overwhelming. The best thing I've been doing is working on time management. This thread is super helpful to read before a shift to remind you of what to focus on and how to prioritize time https://allnurses.com/emergency-nursing/time-management-strategies-272662.html. My preceptor is starting to get big on having all my stuff ready to go into a room and do everything in one trip, be ready to start the IV, know what kind of line and labs you need, put in protocol orders and do a mostly problem focused assessment and do the charting in the room instead sitting down and going back to do it later like on the inpatient units.
Its gonna be really stressful and overwhelming for the first year or so, ask for help and double check complicated meds with other nurses, don't worry about fumbling and being awkward cause everyone's expecting it from new people and it looks way better to jump in and try to learn.
Thats the the best advice I've gotten so far and I've found it wicked helpful. You can do it í ½í±

Any advice on your end???im stuggling with possible differential diagnosis because my memory recall from certain diseases/disorders is a blur to me.

Kitkat7985, BSN · Dec 15, 2017

I totally understand what you're going through!!! I was a float pool nurse and requested to cross train to ER. It was such a reality check at how different the two worlds are!!! Especially to then go to icu from ER LOL! I felt like a complete moron when I first started training in the ER even though I had four years nursing experience under my belt. I remember how intimidating it was initially, and it was very strange adjusting to such a different pace and expectations. You should be proud of yourself for jumping in and pushing yourself beyond your comfort zone! Remind yourself that you are not a new grad- you have a lot of experience and have seen all kinds of different diagnoses and how to react/treat them. You're getting these same patients upstairs ! You have the knowledge, you just have to switch up the way in which you give care. I pretty much had to mentally drop everything I would normally do on the floor, and switch to a whole other mind set to fit the ED. Forget the floor routine and learn this routine with a new set of eyes :) The floor is a more controlled environment with somewhat expected schedules throughout the day, and very detailed assessments and charting. You (mostly) know your patients in detail, diagnoses, course of hospitalization, treatment, etc. ED is the flip side lol. That's what is so exciting though! You are like a detective. You don't know what kind of patient is going to walk through those doors, so you have to use your critical thinking/assessment skills as soon as you lay eyes on them. Your priorities are triage, stabilize, then send them up or send them home. If they need to go up, move them out fast since they will start having new orders/tests rolling through. Plus, there are patients waiting for their bed that need to be helped. This is why the ER and floor nurses can sometimes get frustrated with one another lol. The units are two different beasts. ER doesn't have time to get all of the information the floor may want because its not a priority- they have limited time the patient can sit in the ER... Plus Probably dealing with dual codes and Alphas and combative patients coming in all at once :) ! They just don't have time. I remember when I was a new grad I had an ER nurse laugh their butt off when I asked when their last bowel movement was lol!!! You truly understand both worlds :). If a patient is icu status, get them as stable as possible (so if they code it won't be during transport) then move them out ASAP. Make sure they have iv access before they travel and go to the icu. Have extra staff with you with these patients, esp RT. Always have a monitor on your patient during transport. With your level 1 trauma ER, I'm sure they have an especially organized system in place when initially getting a patient settled, and when a patient starts to deteriorate/code. Whenever we got a patient in, the whole team came in at once and had the patient set up within minutes. It's pretty cool to witness and be a part of. One person would get them in a gown and get them on the monitor/taking vitals, while one person would put an IV in and draw blood to send out, another one getting history/meds to start getting an idea of what's going on, etc .. It was like a well oiled machine and is really impressive. Make sure your rooms are set up, esp with bag, suction, Christmas tree.. start frequent vitals (helps monitor your other patients when you can't check on them as much as you would like). Know where your line cart is, crash cart, where to find emergent items/meds. Be proactive according to your ER (ie chest pain? Get an ekg instead of waiting for the doc order). You will have more independence in that respect compared to the floor where you have to wait or page out to get an order to put in. Remind yourself that you have seen these complaints/diagnoses before with all of your experience and already know different things to expect. But I think whats the most important thing is tapping into your nurse gut/intuition. You've seen those patients on the floor- where you take one look at them and know they're going to crash any minute. You will use this a lot in the ER, which is very important since you don't know the reason why this patient is here. They become priority. Never make assumptions. Even a simple abdominal pain or a walky talky with stable vitals could turn into a total **** show within the next five minutes! Don't rely solely on vitals, since those are often abnormal when the patient is already deteriorating. Make sure you have good access at all times. Go for an 18/20G in a big vein in case you need to bolus/give them blood/contrast. Tell your mates and doc ASAP when you get a bad feeling. Your team is everything since it can get so hectic- everyone takes care of each other's patients. Get to know the people you work with and help as much as you can. If you feel like you're drowning, tell them ASAP and they will step in and help. Accept that your shift will always be unpredictable and that you have to be flexible with whatever goes down :) you won't be able to give super detailed care like you would on the floor because you just don't have the time. So don't be hard on yourself about that, you have to focus on stabilizing and getting people out to where they need to go. Focus on the patients complaint and anything that could relate to that, not a whole head to toe assessment. Keep working on your critical thinking skills... this can always be improved no matter how long you're in nursing! Be proactive with this as well. You can practice doing this with coworkers or friends. Example: someone comes in throwing up blood. What do you expect to do while they are with you? (The answer to every patient is always get them on the monitor, vitals, send out blood and urine, etc....if you don't know what to do in a situation always start with that!). Get at least two large bore IVs in. Prepare for possible blood transfusion. Get lab called in ASAP to start type and screen. Send out labs. Ekg. Spike and prep to bolus at least 1 NS bag since they're probably hypovolemic. Maybe get a pressure bag in the room just in case, and blood transfusion tubing ready. Print the consent out for the doc ASAP. NPO. Freq vitals. If they're diaphoretic and pale you know they're in shock and deteriorating. Meanwhile try to get a history and meds. Drinker? NSAIDs? Etc. You will get better at multitasking this all at the same time. Always think one step ahead. "Prepare for the worst and hope for the best". I always keep an eye on the I'll looking older patients and more stubborn/stoic patients that won't tell you they feel well until they suddenly deteriorate. * I recommend taking TNCC if they don't make this mandatory. Re-Prioritize your patients constantly. Keep paper and pen on you at all times, you will always be needing to write down random stuff lol. Make a cheat sheet to keep on you with phone numbers, door codes, etc. Find a mentor(s) that can help support/guide you, and give you feedback. You can be honest with your peers and just say how you are so excited, but nervous about starting since it's so different, and to please give any feedback to help you be a better ED nurse :) teams are crucial, and they will want to help; They won't let you drown. you are never alone so always ask for help as soon as you have a question or feel something isn't right. Lastly, don't forget about you! Bathroom breaks, keep bottled water at your desk, try at least steal a few minutes for a snack on and off. Sorry for the essay but I SOO know how you feel... and my ideas are all over the place since my last one didn't go through lol anyways, You will be great, just go with the flow and support your team. Let us know how it goes !

Phenomenurse · Dec 25, 2017

Hang in there...

if you're deeply unhappy thats a different story, follow your gut. But if the problem is just the challenges of coping with emergency nursing, hang in there.

I started in the ED and am going on 2.5 years now, I still have challenging days and I don't predict any real form of professional "comfort" until I hit 5 yrs at least. The ED itself is so varied, you can't get accustomed to any one thing because every day and every patient is so different and unpredictable, but thats one of the cool things about the ED too...

DayDreamin ER CRNP · Dec 29, 2017

Don't be too hard on yourself. The ER is a very different animal from the rest of the hospital. It is ever-changing and an ER RN has to be able to anticipate and recognize those changes. The ER nurse is the chameleon of the hospital.

Knowing your ABCs is a priority always. Your seemingly stable 26 year old with an allergic reaction takes priority over your stable 80 year old papaw with the broken arm. Sounds odd, right? But those younger allergic reactors will turn on you in a heartbeat (no pun intended).

You've gotten some great advice already by some of our seasoned ER nurses here. The only thing I can add is based on experience as a coach. I've seen so many nurses struggle with the timing of everything; the charting, the assessing, starting an IV, labs, etc. It is all overwhelming.

I've noticed that so many newbies go straight to that computer and start her charting but never include what the patient actually says. We ask a lot of the same questions in the ER and we are so hot to get all of that documented that we forget to actually lay hands on the patient. Our charting software is template driven so what I'm telling you is based on that....

I tell my new orientees to drop your template in the computer to time stamp the patient and you in the room. After that, step away from the computer and go touch your patient. You can ask all the questions you need to ask while you are putting your patient on the monitor and then doing your assessment and then starting your IV and drawing blood. You can go back to do your charting after you assess if you can't remember it all.

When I chart, I also try to include, "The patient states.....XYZ" I always give his CC, duration, other associated symptoms, other episodes, and other pertinent information. Just answering the template isn't enough. If your patient's CC is abdominal pain, you need to include the type of pain and where the pain is in the belly; LLQ, RUQ, etc.

ie: Pt c/o RLQ "cramping" abdominal pain x2 days. Pt reports associated N/V/D with fever and chills since onset of s/s. Denies melena or hematachezia. Denies sick contacts. States OTC antiemetics have not improved s/s. Denies any new or changes to current medications.

Again, all of this is thinking ahead and asking the pertinent questions to help you and your MD determine a plan for the patient. If your dept has protocols you can initiate, know those backwards and forwards. Knowing why we are ordering these tests will really help you, too.

All of this is definitely overwhelming at first and a lot different from working on the floor in any other unit. The ER is the front line and we are starting with a clean slate with each and every patient and every one of those is different.

Best advice? Listen to your patients - not just what you hear through your s'scope but what the patient is saying and what he/she is NOT saying sometimes. And trust your gut. If is smells like a rat, it probably IS a rat.

HermioneG, BSN, RN · Jan 10, 2018

I just got off orientation and there are three very solid pieces of advice that stand out:

First is that in all kinds of nursing, but ER especially, its important to be tuned in to what one of my preceptors calls the "steps to an emergency." Example: you have a patient who has an increased work of breathing and a SpO2 on the low side. Its easy to get overwhelmed with the history, physical, meds, treatment, plan, etc etc and in getting swamped under everything ultimately missing the bigger picture (especially as a new grad). What is critical in these situations is identifying way before hand how many steps of interventions can occur until a true emergency happens. Back to the patient who is short of breath. What level is this patient at, what can we do right now, and what is the next step for when this current level of intervention doesn't work? How many steps does our team have before this patient reaches a fatal level? This would be my line of thinking (again I just got off orientation so I'm sure more seasoned nurses might have a different opinion and I'm always eager to learn) for a patient who presented with shortness of breath.

In the case scenario with the increased work of breathing and low SpO2 patient. While there are many variables, treating this particular problem has a basic skeleton ladder of steps in which you can escalate treatment until this patient is dead, or the patient can travel back down a level if the intervention works and the patient's condition improves.

No intervention: room air

Level 1 of intervention: sit the patient up and put them on a nasal cannula. If that doesn't work and the patient is still tachypnic with low O2 sats then notify the physician and escalate to:

Level 2: simple mask (our facility usually skips this step)

Level 3: non rebreather at 15 L/min

Level 4: BiPap

Level 5: Intubation

Sure, there might be other steps we could throw in there but that is a pretty basic skeleton of how you could escalate if needed.

So, when your patient is tachypnic and short of breath instead of freaking out, ask yourself how many steps there are to an emergency and/or patient death. Look for your resources and communicate. Let the nurses around you know of the situation "hey heads up my SOB patient over here is not looking too great this is whats going on right now, and I'm going to let the Dr, Charge, and RT know." That way if your current level of intervention doesn't work and you have to escalate quickly your team and those around you know what is going on.

This same preceptor told me that ER nursing is about communication and utilizing your resources. Know how to access policies online, the online drug library, etc etc. Also, don't just look at a patient problem and see it as stagnant. Understand that things can escalate quickly and so its critical to know what resources you have on hand and steps you can take before/during/after the situation turns critical.

My other preceptor, when I was talking about how overwhelmed I was all the time, told me that ER nursing is like playing a sport. I like to personally compare it to baseball. In the beginning the game is going to move incredibly fast. You're going to mess up, strike out, and things are going to blow past you sometimes. But, as you learn the game and get more practice you're going to start actually seeing the ball as it passes in front of you. Instead of striking out constantly and just swinging and wondering where the ball went you're going to start making contact. The game will slow down, and you're going to start feeling better about it and it gets fun. It will get better, you just need to get through this phase and make sure you don't hurt anyone and have a good team to back you up.

The third thing I want to share that BOTH of my preceptors told me is that nursing is a 24 hour job. There will be days where the opposite shift nurse is going to hand you a mess. There will be other days that you get swamped at shift change and you hand the other nurse a mess. Forgive yourself for it and just try your best. Help out whenever and wherever you can.

You'll do great just keep pushing through!

BachRN, BSN · Sep 15, 2021

On 12/11/2017 at 10:13 AM, Ambersmom said:

I don't know if this will help but this something that carried over from my FF/EMT, we always did scenario based training, so for almost my entire career I have conducted scenario training in my head-So I imagine I have a patient who codes, in my head I visualize each step of what I'm supposed to do, for severe bleeding same thing, for resp. arrest or depression same thing. I study the protocols and what my role is then I visualize in my head what I need to do, including starting IV's, watching for sx to change etc. I can say its made a lot of my reactions become almost automatic.

So start with something like a CHF patient who ate a bag of chips...imagine the symptoms/signs they'll have. They're heading to pulmonary edema so you make sure the HOB is up high, you apply oxygen, you listen to lungs, are there rales in all lobes or just the bases?( if the rales are getting high you want an intubation kit handy) you start an IV, you think about what meds might be needed, lasix, morphine, maybe nitro, EKG, etc. The above is not inclusive of everything you might do or need (Its been quite a while since I had a full blown chf/pulm. edema pt) but what I'm trying to say is if you visualize all the steps and equipment you might use/need, eventually it will become reflex. I use to visualize "practice" on my ride into work. This doesn't replace real training and orientation but if definitely helped me. Good Luck!

I know this is an old post but this is a GREAT TIP!