Emergency Nursing Pearls-Things they don’t teach in Nursing school.

[GOMER-RN]

Emergency Department Nursing Pearls-Things they don't teach in Nursing school.

Below are a collection of things observed along the way.

--Respect the fact that ED nursing is a specialty. You can actually kill someone if you mess up.

--Show up prepared, on time and ready to take report. If you were out the night before and are unwell, do not announce it to everyone. Go home. (Re-read the first Nursing Pearl. If you think showing up unprepared and altered is appropriate, seek another profession.)

--You are always one medication away from an error. Have that fear and humility. Most really great nurses have at least one biggie at some point in their career. Don't be obnoxious and think that it won't happen to you. It will at some point, and you will learn from it.

--Learn from your mistakes. Be humble.

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--Nursing relies on teamwork. Know that you are nothing without your Paramedics, techs, HUCs (unit secretary), social workers, and housekeeping. Don't piss them off.

--Always introduce yourself.

--Get confident and comfortable with asking uncomfortable questions. You will wish you had asked about Viagra before you gave that Nitro.

--Never give Nitroglycerin without first starting an IV. Recognize what an unsafe drop in blood pressure looks like” and know how to treat it while a patient and the family members think the patient is dying and they are all in hysterics. Try to do this without freaking out. Be calm.

--Use pt. identifiers and ask allergies before giving any med...even if you just left the room.

--Always have someone do a blind double check of your pump if infusing a med other than saline or LR (Especially if you are new to using the Pump) Specifically double check high risk meds like TPA, pressors, heparin, insulin, Cardizem, etc. Know compatibilities of IV meds how to properly infuse them. Understand what Y-site compatibility” means.

--Know the concentrations of Epinephrine, know the proper route of administration.

--Keep your rooms tidy. Clean up after yourself and clean room after patient is gone if you can.

--Keep up with documentation.

-- If something doesn't feel right, it probably isn't, stop what you are doing and seek help. Be honest and don't wing it. If you feel like you messed up your sterile technique, you probably did. Start over.

--Keep patients informed of their care.

--Don't judge. Treat everyone as if they are a family member. You are allowed to your own thoughts, but give the best care you can. If you have a problem, seek help or ask if you can somehow change the patient assignment.

--If your patient is a Nurse, treat them with respect. Never assume that they know everything that is happening. Explain what you are doing and why you are doing it. Remember, they are a patient. Don't expect that they are familiar with everything and know exactly what they should or should not be doing. They are a very special patient with a skill set that can tell when you are not doing a good job. Try not to be nervous and inform them of all that you are doing. If they have been a nurse for many, many years, ask them how they do certain things and if they have any suggestions. You don't have to use their suggestions, but it is a sign of respect that you value their profession.

--If you taking care of any one from any branch of the military, active or retired, thank them for their service. Recognize if they want to discuss their service and understand if they do not.

--Don't argue with a drunk. Definitely don't argue with a person on Bath Salts or some other illegal drug. Work with Security. They will save you! Send them chocolate.

--You are not required to know everything. Be honest with people while maintaining confidence. People can see through BS. Seek the information and get back to them. It's OK to say I don't know the answer to that question, but I will get back to you”.

--you can never be involved in too many codes. Compressions are a skill and not everyone is good at them. Practice.

--A real trauma or a real code are totally different than ACLS. Know how to work a monitor and unlock a code cart. The words on the monitor always somehow change to Greek when you are nervous. Familiarize yourself with how a 3 way stop cock and pressure bags work.

--BE nervous during a code. It keeps you on your toes. Ask for help if you don't know what you are doing. Don't be a hero if you are unsure of what needs to be done. Egos don't save lives.

--When starting an IV, have a methodical system and be neat with your equipment. It instills confidence and makes you look like you know what you are doing.

--Kids have built in BS detectors. Learn how to talk to them age appropriately. When taking care of kids there are always two to three patients (parents take the most work).

--Kids are not little adults. They are fine until they are not. Do thorough assessments on all kids. They can trick you.

--Don't do a pediatric IV or catheter alone. Have a competent wing man.

--You get one IV attempt on a kid. Know your limitations. Technically you are allowed two, but after you blow the first one, the parents' confidence in you is shot. Good luck attempting the second IV while being on the receiving end of death stares. (Kids who are crashing are a different story)

--Insist that family members sit down if they are present for any procedure.

--If you have to take more than one vial of medicine double check. If you have to access two drawers in the Pyxis or are depleting the stock of med for one patient, double check. Something is not right.

--Do not push Lasix, Morphine, Dilaudid and especially Fentanyl fast....or Benadryl. If you do, have a crash cart and an emesis bag close. Zofran is not a harmless medication. Know side effects and what exactly can happen.

-- Don't give Valium with saline. It turns milky white. Don't give 60mg of Toradol IV.

--If you don't know what med you are giving, look it up. Make friends with the pharmacy and use them as a resource.

--Talk to your patients while you are assessing them. You can assess neuro, breathing, circulation and skin while talking to them and doing an IV. Sure you need to listen to them, but getting them to feel comfortable is your job too. It's a skill that can come in handy and relax the patient. Don't be the Nurse that is so focused on doing an assessment that she or he offends the patient by not listening to their needs. I have actually witnessed a nurse say to a patient, Can you please stop talking and breathing like that so I can listen to your breath sounds”.

--If a med comes in an ampule, use a filter and double check the route of administration. It's almost never IV.

--When taking report do not ask questions of your co-workers just to make yourself look smart or make them look stupid. Listen to report. Let them finish and then ask questions. After report, meet your patients.

--Check with the provider before giving test results, including EKG results. Some providers want to be the ones to share the information.

--There are no stupid questions. If you don't know something, ask. I guarantee you are not the only person who doesn't know.

--Respect all of your co-workers and be courteous and professional. Try not to call the Dr. by their first name in front of a patient.

--Under promise and over deliver but do your best to meet your patients' needs. Extend wait times to a realistic time frame and be honest about delays.

--Be aware of your body language and what you are saying. If a patient gets really upset and starts lashing out, don't get defensive or take it personal (unless you did or said something), most of the time they are just upset and the nurse is the target. Non-verbal communication is important. If there is a problem, gently say to the patient you seem upset. Is there any way I can help you”.

--Stories change 2-3 times by the time the Dr. sees the patient. Learn how to key in on important objective and subjective information.

¬-Any conversation you are having can wait until your patient is medicated for nausea and pain. Especially nausea. Make them feel better.

--Make sure to stay hydrated and go to the bathroom when you necessary. Eat. No one likes a cranky nurse. Taking care of yourself is important, otherwise the patients and your co-workers suffer. Keep a Snickers handy. Nurses are great at spotting low blood sugar in others, but unfortunately do not realize it when they are suffering from it themselves.

--Know the chain of command. Know the rules and culture of where you work. If you see something that looks different or questionable, talk to the nurse (away from patient). They may have learned s technique differently. It is not always wrong. If it still doesn't seem right, talk to the person in charge or management.

--Be a team player.

--Thank you for being a nurse. Keep up the great work and know that you are a valued employee and the backbone of medicine. Nurse keep people alive.

[Jules A, MSN]

Wow this is probably one of the most well written, valuable posts I have ever read. I am going to print it and share with my students. Kudos for sharing this sage advice. I'd recommend changing the title for all nurses, especially our new grads. Thank you.

[scottaprn]

Great list. Wish I had it when I stated ER nursing. A few I would add.

-Someday you are going to have a patient that receives absolutely perfect care and it won't make any rational sense why they died.

-You will always remember your first pediatric code where the patient dies. Make sure you process this with someone's help.

-If you don't care if a patient lives or dies it is time to leave the ER.

-Addiction is a disease. The heroin user who has just been Narcaned is going to be an jerk. It isn't personal you just took away their high.

-Someday that frequent flier is going to come in with a real problem. Dont be so jaded that you miss it.

-Every specialty in nursing is different. When you call to give report and get attitude over something (orders not started or results not back) realize the person on the other end doesn't understand the fact that this was your lowest priority based on your patient load.

-Advocate for your patient but don't be a jerk about it. Playing "I am smarter than you are" with a fellow nurse or physician breaks up the teamwork that you will need next time when you miss something.

-Make friends with ICU nurses. Someday you are going to have a hold who is on a vent and a million drips. Being able to call and ask a question in these cases in invaluable.

-A negative ER work up doesn't mean the patient is faking. It means that their problem isn't emergent.

-Always check splints before you discharge a patient. Incorrect splinting may change a next day follow up with ortho into a medical emergency (compartment syndrome etc) or a long term problem (diabetic ulcers etc.)

-Before you call a provider because of a change think about assessment and nursing interventions to try first. I will pay a lot more attention to your call if you can tell me what the patient looks like since the change and what you tried.

-When you know everything quit nursing and start an educational company and come teach everyone else.

-If the patient has a radiology test that is called normal but the patient's symptoms keep leading back to a different diagnosis as the physician or NP if they will look at the images with you. Sometime radiology misses and sometimes the assessment doesn't match up to the read. Find out which one it is before you discharge a patient.

-If your ER has a social worker or a patient advocate get to know them. Sometimes a frequent flyer disappears after actually getting in to see the specialist who can help their problem.

-If a situation with a psych patient is escalating don't go into the room alone. There is strength in numbers and my jaw really wishes I had remembered that sometime.

-When you are rushed always take time to do the basics and due them well.

-Stay out of the gossip mill. Don't listen to it and don't talk into it.

-Someday you will give and get report that starts with the words "I got my @ss handed to me last night. Be understanding.

-The less busywork you give to your techs the quicker you they are to help you when you need it. They know if you ask you really are overwhelmed.

-There will be days you don't leave on time because you have to help finish something up. Know the oncoming nurse appreciates it.

-If you have to take blood from a suspected DUI make sure you use chlorohexadine to clean the skin and not an alcohol pad. Do this in the presence of another nurse and chart that you did it and who witnessed it. Saved me a day in court.

-Find something outside of work that takes your mind off of work. If all you think about is work you will burn out.

-Know your code drugs forward and backwards.

-Ask the pharmacy to double check pediatric doseage for weight based medications.

[airwaynurse]

Gomer and Scottaprn:

I agreed with most of the pearls you shared. Helpful stuff. Off the top of my head let me say:

There is such an intuitive component to what we do as nurses! The down side is that it takes a great deal of experience to get reliable intuitive sensitivity. "Great deal" is so different from one nurse to another. There are many variables at work in obtaining experience. We are all so different.....

Strive for excellence! Study, train, mentor, and be mentored. Thirst and hunger for it, your patients will require that kind of commitment. Sometimes they will need it more that other times.

EMS guys, especially "crusty old paramedics," are great resources and should be respected for what they do (and how long they have done it). They are not all the same, but some of the most brilliant and astute clinicians that I know and have worked with, in both ED, Ground and Helicopter EMS settings, are not "justa paramedic." Use those resources with great care and benefit.

Get involved in after action reviews or debriefs as needed, they are extremely valuable for improvement in future actions. AARs also foster team cohesion...

If it is your day to go (die) you can't stay; if it is not your day, you cannot go! It won't always make sense! Life is not fair...... Do your best, be vigilant, tenacious and passionate about what you do! You have a calling!

NURSE ON!

[Racer15, BSN, RN]

Be nice to your techs. They can be the difference between a bad day and a straight up awful day. Be nice to EMS. They are just doing their job, they take no joy in overloading you with patients. And when you are nice, and apologize when you are having a bad day and recognize that you are unfairly taking it out on them...they will do favors for you :) Like the day I had a pt that was an impossible stick and one of the EMTs dropped an EJ for me (not even a pt he brought us) because I'm always pleasant with him and I asked nicely. Actually, just be nice! Lol. Obviously don't be a pushover but I try to be pleasant, friendly, and as understanding as I can be within reason to techs, EMS, floor nurses, etc. In three years of ER nursing it has made for a lot of people willing to help me when they sure don't have to :)

[guest769224]

-If you have to take blood from a suspected DUI make sure you use chlorohexadine to clean the skin and not an alcohol pad. Do this in the presence of another nurse and chart that you did it and who witnessed it. Saved me a day in court.

Can someone explain this one to me?

[Christy1019, ASN, RN]

Can someone explain this one to me?

Theoretically the defense attorney for the alleged DUI suspect could argue in court that the presence of alcohol in the sample obtained was due to the alcohol pad prep and not because the suspect was intoxicated. Alcohol dries so fast and is such a small amount that I doubt it would make any real difference, however, defense attorneys just need to give the jury reasonable doubt.

Hope that helped! :)

[Jules A, MSN]

Mods, do we have a sticky feature so this could be put on top of this section of the forum? To me it is posts like this with practical, invaluable advice that are far more important than our never ending vent threads.