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Floor nurse to ER nurse. Help please!

BrayaRN specializes in Cardiac, NICU, ED.

Hi everyone,

I am completely new (8 weeks into orientation) to ER nursing. My previous experience is mostly cardiac/telemetry. I also did a short stint on a general medical floor and in a NICU.

I see many of the threads on this particular board are devoted to new grads. I have been a nurse for a little under 3 years, so I am not a new grad but still a fairly new nurse.

I am curious as to what experienced ER nurses to see as floor nursing habits and how to break them as well. My typical floor patient load was 4 patients and this is the typical assignment in my new job.

My difficulties appear to be:

Getting too attached to the one patient that is respectful and actually sick. I tend to dote on them more and meet their needs probably more than I actually have time for. Yet, I find the care part fulfilling.

Not getting assertive enough with the "faking" patients. These include fake seizures, fake pain, and the patient that fakes somnolence as well. I do have a quiter temperament, but I think my whole 100lbs holds me back as well.

Not being anywhere close to organized. Assessments are due at different times on all patients. I can look and see a patient is not due for 2 hours, but when I think about it again 4 hours have passed and I have to backdate.

Any suggestions or other things to watch out for? :nurse:

MassED specializes in ER.

I believe there is a thread on here somewhere specific to this topic. I want to say it was from an ICU nurse transitioning to the ER. I'll see if I can find it and link it.

LouisVRN specializes in Med/Surg.

How do you know anyone is "faking" anything? Especially pain? While patients may not always manifest pain the same way I'd be hard pressed to know someone if definitely faking it. Also I hope by back dating you don't mean that you are charting your assessment done two hours late as being done on time...

EmmyBnurse specializes in CCU.

Sounds like you need to rearrange your idea of time management. Things are paced very differently in the ER and times are not as set in stone as they are on the floor (ex.assessments every 4 hours, vitals every 8). If you have not checked in on an ER patient in 4 hours you need to work on prioritzing as well. ER is a highly specialized area and it will take time to adjust to the new role. Ask lots of questions and openly communicate with your co-workers so they can help you if you are behind. My experience with ER staff is that they are usually great team players, use them.

BrnEyedGirl specializes in Cardiac, ER.

Time is always a hard thing to adjust in the ER. You can't really schedule anything or have the same kind of routine you had as a floor nurse. I understand your dilemma with the really sick patients. It is very frustrating to have a very ill, sweet little lady that really needs your time,...then the drunk in the next room that you see at least once a week who demands all of your time. I also agree,..you often know exactly who's faking,...usually they were also faking the last 8 times you took care of them,...and then you have the ones who while maybe aren't faking,..are really over exaggerating. It seems that people seem to forget that they are in the ER,..we have emergencies and yes I agree that your sprained ankle probably hurts like the dickens,...it takes a back seat to the MI and the trauma that needs to get to the OR NOW!

Sometimes all you can do is smile and move on. It takes awhile to get used to the pace,...remember you have to stay very c/o focused and some things just have to wait. You'll get there,...watch some of the other nurses you know are good at their jobs,....ask questions,....you'll get your own system and work it out! Best of luck to you! I love the ER and don't see myself working anywhere else for a very long time.

PAERRN20 specializes in ER.

Grow a thick skin. Don't be afraid to speak up.....to the physician OR the patient. Sometimes you just have to say it like it is even if they don't want to hear it.

OP, I am also about 3 years into nursing, I've done it all in the ER though. I am constantly running my patients through my head, thinking what's next, always looking in their rooms as I pass, and I make a point about every hour to give them an update, even if I just say we are still waiting on results, how are you feeling, etc. I don't know how it is where you are, but the ERs I have been in have one major assessment when the patient gets there, and then just charting response to treatment, nurses notes, etc after that. I see my patient every hour, even if I don't talk to them, and I chart it. Are they on the phone, conversing with family? Up to the bathroom, how is their gait. pain meds given, etc. Assessments are more focused and quick. Often you can ask your co worker or CN to check on a patient for you while you are in the sick patient's room. Usually they don't mind and can get the patient simple things or communicate back to you if they need something more complicated. Hopefully your doctors will move patients through fast enough that you don't have too many hours of patients holding in the ER. Good luck!

EmergencyNrse specializes in Emergency Medicine.

hi everyone,

my difficulties appear to be:

getting too attached to the one patient that is respectful and actually sick. i tend to dote on them more and meet their needs probably more than i actually have time for. yet, i find the care part fulfilling.

any suggestions or other things to watch out for?

welcome to the er!

time management will be your biggest asset. spending extra time with a needy patient? sure but it will cost you.

bottom line is that you just don't have the time. you don't. people are waiting 4-6hrs to get that bed.

assessment, treatment and reassessment. it's perpetual...

there is no lull in your duties unless it's slow. done with one patient you get another immediately.

prioritization and critical thinking come next. you have to have a "sense" for the bs.

i caution you to say "fakers" because of the backlash you will receive from those that just don't know.

get in, assess, charting... be as brief as possible and look for orders to treat. you will get a feel for those that are there for knee pain x2 years, dental problems, chronic stuff that is far from life-threatening and put them on the back burner.

you have to be an a.d.d personality not o.c.d. you have little time to be thorough like in other areas. sometimes it serves that my "reassessment" happens as i run past a room and see someone sitting upright and still breathing.

if you have techs that can grab your vitals then your golden. monitored patients get q30 vitals set on auto so if i need to do it myself i know i always have fresh vitals when i blow through. really, no time for that care & comfort stuff if yours is a busy er.

is it right? no but that's the nature of emergency medicine. until they come up with a better way of screening non-acute, non-emergency patients and divert them to other areas you just can't spend the time you're looking for with the ones that need it.

MassED specializes in ER.

How do you know anyone is "faking" anything? Especially pain? While patients may not always manifest pain the same way I'd be hard pressed to know someone if definitely faking it. Also I hope by back dating you don't mean that you are charting your assessment done two hours late as being done on time...

I believe OP means there isn't time to chart, so you obviously have done your assessment, but either edit the time on your computer documentation, or chart the time you DID the assessment. That is ER nursing. You don't have time to jot everything down when you do it. You keep notes and chart when you can. That is the reality. It's a whole different animal than any other area of nursing.

And we all have our suspicions for those ones "faking" their pain for narcotics. Back pain, abdominal pain, etc. You only REALLY know after they've had a million dollar work up and no diagnosis, but received tons of narcs up until they're discharged. And you were the one that called it (if not out loud, but in your head) that this patient had nothing acutely wrong from the moment they hit the room. I trust my instincts and they do not steer me wrong.

Edited by MassED

sistasoul specializes in neuro/ortho med surge 4.

This thread confirms my susupicions that no matter what area of nursing you work in it is insane. Not enough time for charting and no time for TLC. It is this way on the floors also.

System seems to be broke don't ya think?

MassED specializes in ER.

System seems to be broke don't ya think?

It is,..not sure how to fix it.

less patients?

BrayaRN specializes in Cardiac, NICU, ED.

Thank you everyone for your constructive feedback.

To clarify:

I certainly am seeing my patients more than every 4 hours, or 2 for the Level IIs. In fact, like I previously posted, sometimes I spend to much time. My initial assessment is always on time and the most thorough. Everytime I enter a room, I am reassessing just not necessarily charting at the time. My problem is being late with the charting, even though the assessing was certainly occurring on time.

I have yet to understand why there needs to be people who lay into you especially for an innocent post. I do not post frequently on this site. However, when I do it is always where I feel I have knowledge that would be especially beneficial. I answer the question that is asked to the best of my ability. I have never entered on in a post to belittle somebody or start some kind of war of words. I believe my initial post was asking about improving my skills in the ER. I would assume that posts that would follow would answer that initial question. Sure I could get on my high-horse and judge somebody not asking for it just to "improve" my self-esteem and to create some drama. Thankfully, I have better things to do than hide behind a computer screen and make negative comments about people who actually exist behind these screens and come here for advice.

I would ask:

A physician is able to determine the patient is faking a seizure in front of him. However, I am to believe it, because heck it's the right thing to do. How about the fact that the patient was in fact being treated as a seizure patient until the physician determined otherwise.

A gentleman comes in with a sore wrist. The physician orders some ice and an x-ray. The x-ray shows nothing. Computer records, however, show that this patient has travelled to at least 8 other ERs in the vicinity in the last month with the same complaint. During this month he has received Lortab prescriptions on nearly every visit. Sometimes filling a bottle of 6 one night and going back to fill another bottle of 20 the next night. So clearly this patient is not faking pain, this time it is true, and I had better advocate for this patient to make sure that he has another 20 Lortabs to hold him over in case he already used up his other 100?

How about the patient faking somnolence? Hmmm.... nothing is found in the blood work and she is stable to go home. She will not wake up. Then ammonia is held under her nose by my preceptor. Not only does she wake up, but she walks out the door and even apologizes on her way out.

:uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3:

BrnEyedGirl specializes in Cardiac, ER.

Braya,...you will notice on this site that there are many folks who haven't been in your shoes,.have never been in a position to see the same pt over and over for c/o that never have a diagnosis. People who think we as ER nurses are exaggerating when we say Mr Jones has been in our ER 65 times over the last 6 months. He is always c/o of some form of pain, we do the million dollar work up, treat his pain while he's in the ER and send him home with a RX for Lortab, and he walks out of the ER, leaves with friends talking about hightailing it to the nearest Waffle House because "they were trying to starve me to death in here!"

After 40 of those visits, Mr Jones phones the ER to explain how he lost his RX, can I call it in for him,..or someone broke into his apartment and stole his meds,.can I call it in for him,..or the pharmacy calls to inform us that Mr Jones just picked up 20 Lortab the night before, do we want them to fill the RX?

There are many on this site that have never been in the position to try to be at least civil to Mr Jones only to have him swear at you, and spit in your face.

I agree with you,.it is very frustrating to have people like that suck all your time and energy when you have 3 other pts that are really sick and need you.

I am not above telling Mr Jones,.."look,.you've been here enough, you know the routine,..it takes hours to get back all the labs, Xrays, CT's etc. I have other pts to take care of,..sick pts that might just die right here, tonight in my ER if I don't help them. Please be patient with me,..you'll get what you came for,...just not this second." Some of my frequent flyers will chill a bit and I might get 30 min of peace,...others I just call security and have them deal with it.

There will be those on this site that call me cold, and a bad nurse. How do I know Mr Jones isn't really sick/injured etc? I fully expect Mr Jones to show up one night with an actual emergency,...his lifestyle puts him at a very high risk. I also believe that when he does show up with a real emergency I will know it. I have been educated and trained and am quite good at my job and when that chest pain is the big MI I will recognize it and treat it accordingly!

Unless you've walked a mile in my shoes,.....please don't assume I don't know how to do my job. It is vital that I can tell the difference between someone who is sick and someone who isn't. It is my job to triage and treat those who are really sick first,...that's what I was trained to do and what I get paid to do. I have a license, and a family to think about,...would I really blow off a pt that is truly ill just because he's a pain in the butt? Of course not! But it is my responsibility to care for all of my pts and since I can't be at 4 places at once I have to be sharp enough to recognize a true emergency when I see one!

Hang in there girl,...you'll figure out a way to do this. Sometimes people will be angry,....but imagine how angry folks would be if you allowed there child/grandmother/wife to die while you were busy with Mr Jones who again left with a diagnosis of "drug seeking behavior".

Edited by BrnEyedGirl

WonderRN specializes in ED.

How do you know anyone is "faking" anything? Especially pain? While patients may not always manifest pain the same way I'd be hard pressed to know someone if definitely faking it. Also I hope by back dating you don't mean that you are charting your assessment done two hours late as being done on time...

Not constructive or helpful, really.

You've never had a patient that moaned and groaned when she saw you in her line of site, but was then talking, laughing on the phone, ambulating around the room without difficulty the next minute, when she thought no one was looking?

Seriously.

sixpack7us specializes in cardiac, ER, Peds, Med surg, ICU, CCU.

I write everything down in my own shorthand.

MassED specializes in ER.

thank you everyone for your constructive feedback.

to clarify:

i certainly am seeing my patients more than every 4 hours, or 2 for the level iis. in fact, like i previously posted, sometimes i spend to much time. my initial assessment is always on time and the most thorough. everytime i enter a room, i am reassessing just not necessarily charting at the time. my problem is being late with the charting, even though the assessing was certainly occurring on time.

i think most of us have to edit our times of our assessments because we're in the middle of something else to take time to document. it's the nature of er nursing! are you computerized? do you have computers in patient rooms? you might try to document then, even a brief note, and go back and edit if you need to add anything after the fact.

i have yet to understand why there needs to be people who lay into you especially for an innocent post. i do not post frequently on this site. however, when i do it is always where i feel i have knowledge that would be especially beneficial. i answer the question that is asked to the best of my ability. i have never entered on in a post to belittle somebody or start some kind of war of words. i believe my initial post was asking about improving my skills in the er. i would assume that posts that would follow would answer that initial question. sure i could get on my high-horse and judge somebody not asking for it just to "improve" my self-esteem and to create some drama. thankfully, i have better things to do than hide behind a computer screen and make negative comments about people who actually exist behind these screens and come here for advice.

hallelujah! you said it! there are more than a few people who love to get on their high horse and post things to prove (maybe to themselves) how relevant (and super nurses) they are.... don't let it get you down. your post was great. :yeah:

i would ask:

a physician is able to determine the patient is faking a seizure in front of him. however, i am to believe it, because heck it's the right thing to do. how about the fact that the patient was in fact being treated as a seizure patient until the physician determined otherwise.

a gentleman comes in with a sore wrist. the physician orders some ice and an x-ray. the x-ray shows nothing. computer records, however, show that this patient has travelled to at least 8 other ers in the vicinity in the last month with the same complaint. during this month he has received lortab prescriptions on nearly every visit. sometimes filling a bottle of 6 one night and going back to fill another bottle of 20 the next night. so clearly this patient is not faking pain, this time it is true, and i had better advocate for this patient to make sure that he has another 20 lortabs to hold him over in case he already used up his other 100?

how about the patient faking somnolence? hmmm.... nothing is found in the blood work and she is stable to go home. she will not wake up. then ammonia is held under her nose by my preceptor. not only does she wake up, but she walks out the door and even apologizes on her way out.

:uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3::uhoh3:

again, most of us that work in the ed (or have long enough to have experienced these types of patients) know that you are correct.

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