ER New Grad Time Mgmt Help

melissakp · Sep 19, 2020

remember in the ED your are there to address current life threatening events/problems. Example, back pain you need to know how long, any tingling numbness, and any bowel bladder issues. Then the rest is up to the MD. Maybe I over simplified it some may say. But you don't really need to do a cardiac or resp assessment on this pt. just GSC, musculoskeletal and minimal neuro by the questions you ask. Ask questions while getting the vs.

bitter_betsy, BSN · Sep 19, 2020

@melissakp Thank you. This makes sense while I'm sitting here. Back pain, possibly spinal cord/nerve related so check neuro while you are there - and multitask. Hopefully this will stick when I'm in the situation again!!

melissakp · Sep 19, 2020

just remember to focus on only the body area that the complaint is about unless you see something else contributing. You can go back later after you've got all your pts settled, labs and meds done, and do more assessments if you think they are warranted. As a preceptor I try to always ask my new nurse after we leave the room what they think is going on and is there anything they may have forgotten or would like to go back and re-evaluate when time permits. That is the preceptors job.

bitter_betsy, BSN · Sep 20, 2020

4 hours ago, melissakp said:

I try to always ask my new nurse after we leave the room what they think is going on and is there anything they may have forgotten or would like to go back and re-evaluate when time permits. That is the preceptors job.

** This statement makes me realize that I am not set up to succeed. My preceptor sits at the nursing station to "keep an eye on everything" but she has no idea what I'm actually doing in the room. She does look at my charting after I do it, but she isn't in there to speak with the patient, doesn't go back and question the pt, and so how could she possibly know if I'm even assessing properly to start with?

JKL33 · Sep 23, 2020

On 9/19/2020 at 9:31 AM, bitter_betsy said:

My preceptor and many others where I'm at don't even bring a stethoscope to work and for me personally that isn't OK. I feel that I need to get myself in a position where I have time to listen to every patient.

I've seen numerous people who operate the way you described (they might find a stetho somewhere if they really think they must).

I do use mine a ton. But I am selective about which patients and what I listen to.

For some patients (mostly level 4/5) the nurse can get a pretty good idea of pertinent exams to be further performed just based on visual assessment of the situation. Are they breathing fine? Good color? Walking, talking, etc.? Don't forget those are assessments, too. If you have a question, perform the screening (down and dirty) version of the assessments you were taught. Save your time for people who need more than a screening; the ones that deserve a careful assessment or re-assessment.

Wanting to listen to every patient: Some of this is good nursing, and some isn't so much good ED nursing but a train of thought influenced by other factors and other players. Does your employer wish you would document a full assessment on every patient? Likely! I've been on staffs where that was the point-blank mandate. Good for supporting billing, meeting other metrics and (in theory) reducing liability. Otherwise, it's a terrible idea because it is a misuse of the nursing resource of time. Level 4/5 patients require very limited/focused assessment and in fact could easily be cared for in other settings; they do not specifically need an ED nurse to do a H>T exam.

I know it's difficult for people to accept the reality and the ethics of what I'm saying, but if you think about it you know that the function you expect from an RN in any given place has something to do with 1) the place itself and 2) what the patient needs. For instance, if you encountered an RN at an office visit you would not expect them to perform a full cranial nerve exam for your sprained ankle.

Begin asking yourself if what you are doing (or about to do) will facilitate the care that you are responsible for, for that patient.

Example: UTI sx x 12 hrs. Patient otherwise in general decent state of health without other acute concerns. ESI 4.

Question: What assessments can you make immediately upon being in the room and opening the chart?

Answer: General appearance (LOC/orientation, appropriate interaction with others, etc.), airway, breathing status/work of breathing, +/- audible sounds (e.g. stridor, audible wheezing), color/perfusion of skin...

Question: What do I hope to gain/learn by listening to lung sounds?

Your answer: ?

Your possible answers: Maybe you feel that you would ?--find out that they are wheezing super bad without any other sx? Not likely. Find out they have absent lung sounds somewhere and actually have a pneumo without any other sx? VERY unlikely. Pneumonia? TB? Lung cancer? Nah. Regular sound of smoker lungs? Maybe. But that isn't going to change anything you need to do to facilitate that patient's care in the ED.

Meanwhile, while you are making yourself feel better by listening to all lungs, hearts and bowel sounds for the UTI-level patients, you have someone in another room who has a fever, a bad cough and a HR of 140. ? Or chest pain. Or neuro changes. Or any number of things that can be assessed right from the doorway/first glance as being much more serious than the simple UTI, sprained ankle.

So...what you wish you could do or what you have been trained to believe you should always do in every instance (listen thoroughly to every sound on every patient) sounds good, but in reality it is going to amount to poor patient care in the ED.

The name of the game in the ED is performing relevant assessments quickly and moving on to appropriate interventions.

I think, in order to facilitate your learning and growth as a nurse and improve prioritizing, you should do the above mental exercise with most patients. Especially since your non-preceptor is not teaching you.

If you want to talk through some of the real-life decision-making scenarios about how to assess patients, just post them here and I'm sure people would love to chime in.

?

JKL33 · Sep 23, 2020

I can hear some rebuttals and what-ifs in my mind already, so I want to make it clear that I'm not advocating blindly making a nursing plan based upon someone else's triage or the ESI level someone else may have assigned.

I'm just saying that you can take in a lot of information from the second you begin interacting with a patient, and you can use those assessments to guide your care and prioritize so that you are using your time in the best interests of all.

bitter_betsy, BSN · Sep 24, 2020

@JKL33. Thank you so much for taking the time to write such a thoughtful response. I know that I don't need to put my stethoscope on every patient that walks through the door, but I feel like I should listen to lungs and bowels when appropriate. For example - bowel sounds for the 11week preggo momma that's complaining of constipation, who had abdominal surgery prior to her IVF treatments and has experienced peristalsis in the past (I did listen to her for about 10 seconds which was long enough to hear something in each quadrant). On the flip side, I had a fella come in who was not in good shape at 74% on room air. While the triage nurse was getting a line in him, I was getting him on a rebreather until respiratory could get there - I never did listen to his lungs. I probably should have, but by the time I got the lasix in him and the external catheter attached, it was time to start on his K bomb (15 min before shift change) and I just never listened to him. He needed dialysis, so listening to him really wouldn't have changed anything anyway. I am learning how seconds can matter and sometimes those seconds can be used elsewhere (like gathering supplies to get a line). While I was doing the kbomb, a patient in the next room over (who had a-fib w/ RVR) ripped out her IV line. I was trying to get a new line on her, while the calcium was running on the other pt. I hate having admitted patients in the ED - especially ones that are altered

I honestly wish I just had a good preceptor who would guide me on the front side instead of just correcting me on the backside. Initially, I thought it was great that my preceptor wasn't hovering all the time because I wasn't as nervous. I have realized, that I feel as if I am in this completely alone and the only time I'm provided direction is when I make the wrong choice, or could have made a better choice - I'm told what I should have done instead. I really feel like I'm doing this alone and I'm afraid that I'm going to get dropped from my residency program or the ED all together.

Last question - is it normal for your preceptor to remind you at least once a shift that Med Surg isn't a terrible place? I mean I know that it isn't terrible and its an option, but its not an option that I chose for me and I got hired into an ED residency program and they are spending a pretty penny to train me specifically for the ED. Why is she constantly having this conversation with me - is it because she is burned out and wants out?

JKL33 · Sep 24, 2020

48 minutes ago, bitter_betsy said:

Last question - is it normal for your preceptor to remind you at least once a shift that Med Surg isn't a terrible place? I mean I know that it isn't terrible and its an option, but its not an option that I chose for me and I got hired into an ED residency program and they are spending a pretty penny to train me specifically for the ED. Why is she constantly having this conversation with me - is it because she is burned out and wants out?

TBH I don't like her style (by the sound of it) and I wouldn't care too much what she had to say about anything unless she decided to get up and start actually precepting.

??‍♀️

JKL33 · Sep 24, 2020

aaaand on second thought:

Although I wouldn't be able to care about the opinion of someone like this, I might still want to know what it is in order to know how to maneuver.

Consider asking her the next time she brings up med/surg (use careful tone of voice). "How do you think I doing with my learning?...." or "Are you thinking that I should consider med/surg?"

It would be nice to just ignore her (other than paying attention if she says you have done something wrong), but realistically you might want to somehow get an idea of her thoughts on your performance so you can talk to someone (educator/manager) and not wait until she starts escalating her "concerns" a week before your orientation is supposed to be over when it's too late for you to possibly change the minds she has poisoned.

bitter_betsy, BSN · Sep 24, 2020

@JKL33 I was asked today in a residency class how my precepting was going and it has led to an appointment on Monday. I just had a meeting last week regarding the situation where they put us in a room and let us talk about it. She is such a personality, that I just backed down and let it go. It was terribly uncomfortable. I was in an abusive marriage and I know when it is pointless to speak. I tried to get the appointment before I have to do 2 more shifts with this person, but I was unsuccessful. Monday will have to do. I do believe that my training coordinator's view has been persuaded, but maybe this appointment will help fix that. Maybe they can interview the 4 nurses that have come to me and said that the way she speaks to me is inappropriate. I admittedly have issues confronting controlling people that need to be in my life, but its based on fear that the situation will just get worse. My viewpoint is that I know where I stand right now, so if I just keep my mouth shut, it won't get worse. Manipulative people suck.

bitter_betsy, BSN · Sep 24, 2020

Oh and she tells me "you're doing great", followed by the med-surg. Its like a game. She says that she likes that I take ownership of my patients and that the other residency students have to be told what to do. Maybe her teaching style is "tough love" and everyone else is getting hand holding... I do occasionally get tossed a "you're doing great" cookie, but the negative comments overshadow them. I don't need unicorns, and I'm fine with being told where I need to improve - its just how those comments are being communicated.