How to think like and ER nurse

MedicFireRN · Mar 22, 2016

The biggest thing I can tell you from years as a medic/ER tech and as a fellow new nurse in the ER (hi friend!) is that it is of the utmost importance that you constantly re-triage your patients mentally. As in, I walk by the room and I lay eyes on the patient. Usually that gives me enough info that they haven't had a status change. Depending on who is coming in and who you're discharging, your sickest patient can change by the minute.

Also, never take anyone's word as to whether or not your patient is sick unless you really know them and trust them. I personally won't take anyone's word on it- I always look at a pt new to one of my rooms before deciding if my priorities need to change. "This guy is here because he was at skilled rehab and they stopped giving him his pain meds" can turn into "they also didn't give him an antibiotic" and he ends up being septic.

I'm all ears if anyone has some great organizational tools, but it's seemed to me like ER nurses just kind of have to go with what comes up and the triaging of priorities is ever important rather than having a set flow/organizational guide. While you are orienting, look for tips from your preceptors about how they prioritize and organize their tasks.

Some books I've purchased that I have found helpful to get into the ER Nurse mindset: Sheehy's Manual of Emergency Care, Fast Facts for the ER Nurse, and the Emergency and Critical Care Pocket Guide.

:) Good luck! I am loving it so far even though I just started working as a nurse; the chaotic ER environment is very much home to me.

Nalon1 RN/EMT-P, BSN, RN · Mar 22, 2016

Organization? What is that? Controlled chaos maybe. :wacky:

I came from IMU/ICU to the ER (but was a paramedic for many years before that). There is no comparison, you come in running and leave running some days. As said above, it is a constant reassessment of priority. Your sickest patient that needs all your attention my be replaced by the the new even sicker patient in one of your other rooms. It is always fun having 3 patients that if on the floor would be 1:1, yet in the ER it is normal to have them by yourself.

Heck, last Saturday I had a patient in a major room, BP 52/34, AMS, major active GI bleed, 2 units of blood going, 2 already given, 2-3 liters of NS, and we had to move her to the hall for the CPR coming in. Luckily my other 3 patients were minor in comparison (pancreatitis, a general abdominal pain, and a broken foot).

You just can't plan for that. You will have to learn to roll with it and make adjustments on the fly.

Lev, MSN, RN, NP · Mar 22, 2016

I will second the constant re-prioritization. Also, always eyeball your patient when they first get back to the room, even if you can't attend to them at that moment. Also, try as much as you can to document as you go. Will save you headaches later. Please use security and police PRN.

akulahawkRN, ADN, RN, EMT-P · Mar 22, 2016

In one sense, nursing is nursing... however the ED is just a bit, well, different. You're going to have (typically) 3-4 patients at a time and you'll be constantly re-evaluating them mentally. The other day I had a patient that was in our "fast track" area that quickly went from a relatively "simple" shortness of breath to being in respiratory failure, ending up on a vent, with me going from 3:1 to 1:1 for a while and then back to 4:1 with the vented patient still under my care. All told, I think I had something like 12 patients that day, in total. I'll do the initial assessment, charting, watch for various orders, implement them as necessary, and discharge patients.

Another thing you'll end up getting used to is doing your med passes right NOW because everything done (generally) is now. There are very few scheduled medications ever given in the ED. I've gotten away from the time management part of MedSurg nursing (only done in school though) for doing the med pass quite simply because I don't have to prioritize the med pass across my patient load. One thing that gets a little irritating is that sometimes when I'm discharging a patient, our providers will put in a med order that needs to be implemented within 30 minutes. By the time I've done the discharge teaching and reset the room for the next patient (takes about 10 minutes if the patient is ready to go) I now only have maybe 20 minutes to gather the medication and give it. Sometimes that also means starting a line, drawing blood, priming a drip set, etc all before administering the IV medication. Hopefully the patient isn't so dehydrated that they have very few options for establishing a line... or my favorite, the patient is both "fluffy" and dehydrated.

Then when you think you've caught up on everything and all is calm... it all changes because someone uttered the "Q-word." I never utter that word at work. Never. I'm not superstitious but I've been around long enough to never utter it.

Working in the ED is just learning to strap on your roller skates, roll with the punches, and flow with the chaos. Controlled chaos is a good way to put it. Prehospital work is actually worse in that regard... but the ED never really gets a routine like MedSurg can have. I also very much depend upon my team at work (and it's also why we do 3:1 instead of 4:1) because of those times when I must go 1:1 with a patient. Teamwork is paramount and everyone picks up another patient when this happens just to keep things flowing well throughout the department.

Lev, MSN, RN, NP · Mar 22, 2016

The full moon phenomenon is real.

rearviewmirror, BSN, RN · Mar 22, 2016

Everyone is either level 1 or level 5. You have one priority and everything else can wait. You are not there to make patients happy, you're there to save lives and get stuff done. Don't believe what patients say, believe the vitals and physiological signs. Be tough and be firm. You don't owe these people anything. Help out when your coworker is drowning. Get stuff done quick, don't let the "customer service" get in the way of getting things done. Lastly, humanity is more pathetic than you imagined.

Susie2310 · Mar 22, 2016

One thing that gets a little irritating is that sometimes when I'm discharging a patient, our providers will put in a med order that needs to be implemented within 30 minutes. By the time I've done the discharge teaching and reset the room for the next patient (takes about 10 minutes if the patient is ready to go) I now only have maybe 20 minutes to gather the medication and give it. Sometimes that also means starting a line, drawing blood, priming a drip set, etc all before administering the IV medication. Hopefully the patient isn't so dehydrated that they have very few options for establishing a lineâ€¦ or my favorite, the patient is both "fluffy" and dehydrated.

Why you are discharging the patient if they are dehydrated?

An ER physician started the discharge paperwork for a family member of mine who ended up being admitted for sepsis and spending three days as an inpatient in hospital. The ER nurse didn't advocate for my family member at all, and told us that the doctor was getting ready to discharge my family member, and that she was going to bring us the paperwork. I told my family member (who agreed they were far too sick to go home) to refuse to sign the paperwork, and they agreed. At the time, my family member had a fever, was hot and flushed, tachycardic, BP was elevated for them, and they had an extreme and sudden onset of weakness. (Of note, my family member had been discharged from a previous hospital stay within the last 30 days).

After giving initial fluid boluses and the first round of antibiotics the physician was very keen to discharge my family member, in spite of the above symptoms being present. Thankfully the physician changed their mind before we had to refuse to sign the discharge paperwork and explain why we couldn't sign, and admitted my family member to a monitored unit. I would hate to think that my family member having been discharged from hospital within the last 30 days could have influenced anyone's thinking in regard to admitting/discharging them when they presented at the ER within a 30 day time frame($).

Nalon1 RN/EMT-P, BSN, RN · Mar 23, 2016

Why you are discharging the patient if they are dehydrated?
...

I think they are saying while discharging one patient (patient "A"), orders are placed on another of their patients (patient "B").

By the time they are done discharging patient A, they only have 20 minuted to do what they need to on patient B.

Artsy_RN · Mar 23, 2016

Most acute to least acute is always the priority to follow. Ask questions if unfamiliar with a procedure or medication. If you get a female pt under age 50 always ask for urine first before working them up for a upreg (this will save you alot of time if they may need xray or get ordered toradol, etc). Your floor experience will help if you have ER holds and/or ccu/icu admit with a million stat orders to complete before you can bring them over. If you are drowning ask for help and offer help if you see someone else drowning. ED is all about teamwork, especially when there are 15 holds with 35 in the waiting room and 4 hour waits. ..

akulahawkRN, ADN, RN, EMT-P · Mar 23, 2016

Why you are discharging the patient if they are dehydrated?

Perhaps I wasn't clear enough for you. What's below is the point I was attempting to convey.

I think they are saying while discharging one patient (patient "A"), orders are placed on another of their patients (patient "B").
By the time they are done discharging patient A, they only have 20 minuted to do what they need to on patient B.

Of course, that's just patient B. There's often also a patient C and D that may also have "stat" or "now" meds that also need to be given.

bgxyrnf, MSN, RN · Mar 23, 2016

As someone who has worked in four different Northern California emergency departments, let me start by saying that there is no uniform experience nor rules. What is necessary, expected, or accepted in one facility may not be in another.

In one setting you may have RTs, pharmacists, phlebotomists, and techs. In another setting it may be just you and a doc.

In one setting you may be drilling intraosseous lines, placing IVs by ultrasound, drawing ABGs, doing internal cardiac compressions, or giving RSI meds - in other settings, you may not even be drawing labs.

In one setting, "straight to the OR" may be the word while in another, you may be sitting on that patient waiting for critical-care transport. In one setting, that transport might be a helicopter while in another, it might be you in the back of an ambulance because weather prevents aircraft extraction. In some facilities, or with some docs, you have a great deal of autonomy with the sure knowledge that the doc will back you up. In other places, though, you better not even start a saline lock without a direct order in place.

In one setting you might have your own dedicated police officers while in another the nearest cop might be 30 minutes away.

All that to say that (1) all the opinions on AN reflect the experience of the poster and may not apply to your situation and (2) learn the expectations and authorities of the place that you're working.

The ED is unlike anything else in the system and most people either dig it or despise it.

(And for heaven's sake, please do your part to tearing down the walls that so commonly exist between the ED and the ICUs... we're all on the same team but our roles are sooo different.)