How do you know you are ready?

Sassy5d · Sep 15, 2013

All I can say is, repetition. We didn't just wake up totally amazing nurses. ?

I see a lot of the same thing. I know when someone comes in complaining of chest pain, it's line, labs, EKG. Investigate the cc.

Abd pain: urine, line, labs.

A critical pt is going to need 2 lines, a whole bunch of labs, ect ect.

It's repetition.

Even where you're working now. You'll get faster and faster, through repetition.

WAheartnurse · Sep 16, 2013

I am training in the ED after being on a cardiac floor for almost 2 years. I think that was a good time frame. Dont worry about how fast you can throw a foley in- that will come. You just need to know that if your patient can't pee and you need to give 2 liters of fluid, IV lasix, that you need a foley (and probably before you give the IV lasix). That kind of logic and priority setting comes with time.

Also, look at what you are doing every day as preparation for the ED (triage and prioritization). STAT IV lasix for the guy with SOB, IV dilaudid for the lady with hip fracture and 10/10 pain, new admit with sepsis and BP of 85/40 and a stack of new orders, and a STAT discharge so they can move everyone around to make room for the cooling protocol post arrest patient on the balloon pump. What do you do first? What do you delegate to the person who says to you "do you need a hand?" What can wait? That will all be invaluable when you go to the ED.

Also, when you go to the ED, the doctor is right there. You do very little detective work and alot of following protocols set up for best patient care. Female abd pain? Do steps x,y,z. Non-cardiac chest pain? Do d, e,f,g. You don't figure out the WHY, you just give the docs the puzzle pieces (the n/v/d just came back from out of the country)(the kid that "can't breathe" is playing happily in the room and singing songs)(your gut says I need some help now- even though you can't put a finger on quite why yet).

I am a little disappointed in how little time I get to spend with patients in the ED- in fact very little assessing gets done- the doctor is often right behind me to look and listen so I don't even listen to heart and lungs for most folks. The techs do splints and laceration stuff. I check them in, give meds, and send them home or upstairs.

On the floor, you take care of the whole patient. In the ED, you only do what the complaint is- and just enough to keep them going until they can see a primary doc (or stabilize them to send them to the floor).

Still it is a ton of fun and every day is different.

nurseinnyc&nj, BSN, MSN, RN, APRN, NP · Sep 17, 2013

I started in a busy level 2 trauma center ED as a new grad exactly 2 months ago with zero nursing knowledge and clinical skills except what i learned in school which seems to be totally different in real life job! lol and i have to say although i have no idea what kinds of patients ill be receiving in my ED, i can at least get prepared and expect what to do now......i finally learned what kinds of standing orders to start on my own for patients with common reasons coming to ED- abdominal pain, chest pain, asthma etc....everything seems very repetitive for me now...i still have 2.5 more months of new grad orientation left....but i feel pretty confident with my prioritization skills and any skills commonly needed in ED settings with my 2 months so far and feel like im getting the hang of it!! And i have to say i love the fast paced environment so much!!! Good luck!! If you already have tele experience, im pretty sure you will be able to adapt to ED very quickly.

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itsnowornever, BSN, RN · Sep 23, 2013

I am training in the ED after being on a cardiac floor for almost 2 years. I think that was a good time frame. Dont worry about how fast you can throw a foley in- that will come. You just need to know that if your patient can't pee and you need to give 2 liters of fluid IV lasix, that you need a foley (and probably before you give the IV lasix). That kind of logic and priority setting comes with time. Also, look at what you are doing every day as preparation for the ED (triage and prioritization). STAT IV lasix for the guy with SOB, IV dilaudid for the lady with hip fracture and 10/10 pain, new admit with sepsis and BP of 85/40 and a stack of new orders, and a STAT discharge so they can move everyone around to make room for the cooling protocol post arrest patient on the balloon pump. What do you do first? What do you delegate to the person who says to you "do you need a hand?" What can wait? That will all be invaluable when you go to the ED. Also, when you go to the ED, the doctor is right there. You do very little detective work and alot of following protocols set up for best patient care. Female abd pain? Do steps x,y,z. Non-cardiac chest pain? Do d, e,f,g. You don't figure out the WHY, you just give the docs the puzzle pieces (the n/v/d just came back from out of the country)(the kid that "can't breathe" is playing happily in the room and singing songs)(your gut says I need some help now- even though you can't put a finger on quite why yet). I am a little disappointed in how little time I get to spend with patients in the ED- in fact very little assessing gets done- the doctor is often right behind me to look and listen so I don't even listen to heart and lungs for most folks. The techs do splints and laceration stuff. I check them in, give meds, and send them home or upstairs. On the floor, you take care of the whole patient. In the ED, you only do what the complaint is- and just enough to keep them going until they can see a primary doc (or stabilize them to send them to the floor). Still it is a ton of fun and every day is different.[/quote']
I have to say I do A LOT of "detective work" especially when a new doc is on. We have a few experienced docs who will let me think out loud at them- example: hey doc, this is what the pt says. This is what labs say. This is the ct and what I'm seeing. Can I give XYZ and then ABC? I think it's _______. Am I right?
In the case of the new docs who seem to fall behind: we have XYZ situation. Can I order X-rays, labs and start fluids with some pain mess and zofran? I'm thinking the problem is _______.
There is a lot of detective work. You figure out the common ties to most problems. And can run with protocols from there. With no "detective skills" you wouldn't know which protocols to begin or be able to turn on a dime and anticipate 3 possible diagnosis. You do have to be ready to jump any way.
ER is a totally different beast. It just is.
Posting from my phone, ease forgive my fat thumbs! :)

zmansc, ASN, RN · Sep 25, 2013

There is no set time limit, schedule, or path from nursing school to ER RN. The bigger question should be what skills should I gain either in nursing school, or elsewhere that will help me when I start trying to work in an ER? I think the biggest skills that help you in the ER are your understanding of the pathophysiology of the various diseases you are going to see and your assessment skills.

I say this because these are the skills that I see in use everyday by the best of the best in my ER and elsewhere. In the ER, you have to think on your feet ALOT. You have a limited amount of time to determine what is going on with the patient, what is going to be needed next, etc. Is this patient really a 4, or are they a miss-triaged septic 2?

You don't have to have those skills fully developed going in, but the stronger you are in these areas, the more you understand how the various six seemingly unrelated symptoms are actually related because this pt is also a diabetic, or whatever it is, the more likely you are to be able to figure out what is going on before the doc gets there and be ready to treat in the now, having already started to treat because you knew the orders were coming for the most part.

RN-CEN TS · Oct 4, 2013

I have to agree with itsnowornever, an ER nurse is not just a person who completes a lot of tasks timly and able to prioritize those task appropriately. If you work in an ER that only has attending physicians it may be an hour or two after the patient is roomed before a physician sets eyes on the patient. You want to be able to gather all appropriate information (s/s, hpi, pmh, and sometime basic tests such as ekg, POCT on urine, visual acuity, ex.) and be able to "present" your patient to the physician so you can get further orders. This helps increase through put which is a major problem in the ED. Secondly, I do not want to keep checking on my patient two hours later with no new info and apologize nothing is happening, those are unhappy patients.

All of these skills, including establishing your own gestalt on presenting patients, comes with time. I started out a new grad in ED wih a MD residency program. It fosters an environment of constant learning, and sharing of information. Resident physicians, mainly interns, are very unsure of themselves and their own clinical perceptions of patients and thus are very open to your perceptions of patients prior to reporting to their attending physicians. I suggest finding an ED with an MD residency program. I have only been an ED nurse for 1.5 years and took my CEN at 1 year. I felt very prepared due to my work environment.

Good luck.