New Grad Starting in ED - Advice on Good Assessments

SeaH20RN, BSN · Sep 2, 2012

Congrats! I was also a new grad who started out in the ER after Graduation. During th 1st year things went...honestly? ..... just "OK" ! I was very scared and didnt know what kind of PT. would come in next. Even though I had always want to be in the ER, I felt I did miss out on some opportunities I could have used in the ER, by not having any Med/Surg floor experience 1st. Just dont get over your head and ask a lot of questions.

Remember you could have everything from OB, PEDS, Cardiac, Oncology, Elder Care to Abuse and Ortho and Neuro all in the same day. I love the ER. Good Luck!

RNCEN · Sep 2, 2012

Good luck to you starting your new gig! I too start my new job as an RN (new grad in May) in the ER in one week. I'm very excited, and nervous at the same time. Ask lots of questions, and remember that help is always nearby. We need to be confident...but not overly so!! Being nervous and cautious is a good thing!

libran1984, ASN, RN · Sep 3, 2012

HA! I was working fast track and read some of the fast track patient assessments by one of the RNs.....

Pt 1:

A/Ox3. Hx of Cdiff. Recent blood noted in stool x8 hours.

Pt 2:

Fell yesterday in ED. Presents today with hip and knee pain bilaterally.

Pt 3:

Believes she may be pregnant due to multiple positive UPT's

Those were examples of our RN assessments today in Fast Track.

Our hospital also makes all RN assessments simple check boxes for different body systems. Click Click Click Assessment complete.

When you're running around like a chicken with your head cut off, you could write out a very detailed assessment in the flow-sheet, or you could get to doing orders and use the check boxes. /sigh.... somedays, i feel assessment skills fly out the window

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I get mad props on my assessment skills in my ED and I moved into my second year of ER nursing. A good generalized written flow sheet assessment could even go like this.....

"Pt presents to ED with c/o..... (why pt is here) x (how long s/s persisted).

Pt ranks discomfort / pain a (#/10).

(Insert focused assessment- ie: use your head to toe assessment skills learned in school but focus only on that one system)

Pt Hx includes....

Bowel and bladder question

Pregnancy question

Call light in reach. Pt voices understanding of current plan of care. Family at bedside.

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So to make one up off the top of my head....

Pt presents to ED with c/o worsening RUQ abominal pain x 3 days. Pt state pain is "consistent & sharp, like it never goes away" pain ranking 9/10. Pt denies previous Hx of current c/o.

Bowel sounds are normo-active x4. Abdomen is soft and non-distended. Tenderness upon palpation per pt in RUQ.

Medic line 20G LAC. 150 mL NS successfully infused by medics. Infusion discontinued upon arrival to ED. Pt seen at St. Jane Doe ED last night for similar s/s. Pt Dx'd with bladder infection.

Pt denies dysuria, urinary frequency, hesitancy, anuria, or pain upon urination. Pt denies fever, chills. Pt professes to outstanding hx of ovarian cysts, commonly treated with Norco Rx. Last menstruation stated to be approximately 1 week ago and WNL per pt.

Pt states BMs are WNL and denies dark tarry stools or bright red blood.

Denies chance of pregnancy.

Call light in reach. Family at bedside. Pt voices understanding of current plan of care.

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The assessment included

1. primary complaint (HOW LONG and complete with a SUBJECTIVE DESCRIPTION as well as if this c/o is something NEW or OLD.)

2. Nursing assessment (notice its similar to your GI assessment in your head-to-toe assessment)

3. Hx leading directly up to current ED visit.

4. Previous medical Hx for pt

5. always ask about urinary and BM outputs because they factor into almost every system in one way or another.

6. Pregnancy does F-ed up things to the body, so might as well ask, particularly if u suspect a CT or Xray.

7 Call light in reach. Family at bedside. Pt voices understanding of current plan of care

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Good luck.

Sugarcoma, RN · Sep 3, 2012

Assessment is an art-form. It truly takes time and experience to master it. I had no previous patient care experience before becoming an RN, just clinicals. I was so intimidated by the experienced nurses because they made it look so easy and they could say exactly what was wrong with the patient. I could not. All I could do in the beginning was identify that something didn't look right and then bring it to the attention of someone else. That is o.k.! With time and experience I began to recognize what my patient's diagnosis might be and the treatments I could anticipate and you will to.

Some helpful advice for all new nurses regardless of where you are working: Always eyeball your patient, follow your abc's, and treat your pt. instead of the monitor! Do not pretend you know what you are doing if you do not. As soon as you feel unsure, grab someone who knows! Familiarize yourself with the types of O2 delivery systems available, when to use which one, where to find them and how to put them together. Know how to hook up your crash cart. Be very nice to your RT and memorize their phone number! Identify coworkers you can trust/seek advice from and vent to. Study common conditions and treatments on your off days. Never be afraid to ask questions no matter how stupid you think it may be! Ask tons of questions! Be humble and willing to take criticism. If a more experienced nurse asks you if you are sure you really want to do something, you probably do not want to do it! Do not participate in gossip/bashing sessions.

In my opinion you could not have picked a better place to hone your assessment skills than the ED. Good luck to you and remember that the transition from student to practicing nurse is a very rough one so be kind to yourself!

apocatastasis · Sep 3, 2012

A bunch of random things:

My most difficult thing coming from ICU was getting to the point where I wasn't anal retentive and obsessive about every detail. Nursing school makes you obsess over details. In the real world and especially the ER, details are great if they are relevant... but many people provide lots of info that has nothing to do with what you are concerned with. (E.g. in triage, "What brings you in today?" can start off a story like, "Well I was at my uncle bob's a couple of months ago and he had a sandwich and I like blue posters and....[ten years later, talking but still no answer]." Ok... so, again... why are you here today?)

Consider your chief complaint and ask yourself... is this detail important? Do I need to follow up on this? Redirect the patient if they get off track and focus on the NOW. Your focus in the ER is NOW. You don't need to be rude, but cultivate the art of turning the conversation towards the issues at hand. You deal with chief complaint and potentially life threatening issues. If they come in complaining of a stubbed toe or jock itch but their BP is 220/125 or 82/40... which is your priority, the CC or the BP? If they come in saying they want a refill of their clonazepam, and can you do a pregnancy test, and can you check their BG because they're peeing a lot and last time this happened they ended up in ICU, which is your priority? You will have patients where your major concerns are not even on the patient's radar, and vice versa..

You will develop assessment skills as time goes on. I used (and still use) our charting system's templates for each variety of chief complaint as a cue to remind me what to ask. Know your body systems, especially neuro, cardiovascular, and respiratory. Problems with these systems can make your patients crash very quickly if not caught soon enough.

Review how to do a basic neuro exam. Review signs/symptoms and treatment of common but potentially life threatening conditions that should always be in your differential depending on chief complaint (off the top of my head, especially MI, COPD, PE, pneumothorax, A-fib, CVA, renal failure, status epilepticus, aortic dissection).

See your sickest patients first. Put the patient on the monitor if you think the issue is serious; treat the patient and not the monitor, but the monitor is a great thing to have sometimes and has saved or alerted me many times (it has also irritated the hell out of me for no reason an equal number of times.)

For psych patients, you need to do a medical screening but also remember that the environment can provide lots of life-threatening utensils if they are really suicidal. Patients can try to kill themselves and/or staff with monitor cables, bedsheets, trashbags, metal forks. Always assess your environment (takes no time but frequently ignored).

Your hospital should put you through a critical care course to help you review info about patho diagnosis and management as well as assessment.

CoolhandHutch, MSN, RN · Sep 3, 2012

The hardest part about assessing patients in the ED is trying to figure out what to do with those that have very vague complaints...and making sure they are not ominous. For example, a 20 year female that states "I just don't feel good. I threw up once today" can be very different than the 80 year old that states the same thing. Zofran ODT and OTD for one, ECG and labs for the other. I always quote the patient on their initial complaint and let that determine my assessment. You won't have time for head-to-toes but if some says they are SOB- listen to heart & lungs, check for edema, move on. You will find your groove in time.

linnaete, ASN, BSN, MSN · Sep 3, 2012

Start collecting your information from the very beginning. If you bring your own pt to the room, evaluate their gait.. any SOB while ambulating? Were they eating a biscuit and laughing on their cell phone in the lobby, or eyes rolling deep in an emesis bag? Ask lots of questions, be nosy. Be polite, but be nosy. Try not to forget your communication skills... developing relationships early can help you out big time during your assessment and after. Just learn to filter what's relevant & what isn't. If you can, stay in the room while the dr/extender is visiting the pt and learn what they are looking for. When you get report from other nurses, compare what they tell you/assessed with what your assessment is. GO TO ALL CODES (if possible). These things have helped me in my short time in the ER so far, still lots to learn!

Esme12, ASN, BSN, RN · Sep 3, 2012

Keep it simple.......if the aren't coding.

Hi my name is......What is your name? How old are you? Are you allergic to any medicines? What medicines do you take?

Have you ever been in the hospital before? What for? Have you ever had any surgeries. For women.....when was your last menstrual period. For vag bleeders....how many children do you have....how many pregnancies? For all....when was your last tetorifice shot.

As you talk you are assessing the patient to get undressed observing for SOB, limited movement, pain. Then ask.......other than the friend/family member/ambulance that brought you here today....what made you need to come and see us today? Then your focused assessment........for example.....if it is chest pain one a scale of 1-10 what is your pain? Does it hurt to take a deep breath does it go anywhere does anything relieve it?

This is where any nurse, but especially a new grad will find it challenging....the first year is the hardest. You are learning how to apply what you learned in school......get the basic organizational skills down pat. Now you are adding rapid fire assessment skills to the list. It is doable but challenging. DOn't get discouraged. The ED is a fast paced unforgiving environment and you will feel over whelmed but don't give up.

If they look sick....they are sick. Teens LOVE drama. A crying baby is a good sign a silent baby will code. It is s ton of learning......but worth the reward.

That Guy, BSN, RN, EMT-B · Sep 3, 2012

Some helpful advice for all new nurses regardless of where you are working: Always eyeball your patient, follow your abc's, and treat your pt. instead of the monitor!

Oh please people do this! I had a critical patient come in who was on the verge of crumping the other night and when we hooked him up to the 3 lead it showed asystole. Of course this got the attention of everyone around and they came running. I told them to back off look, he is awake, talking and moving around. Lets get a stat 12 lead and go from there.

The key with ER is focused. You have to focus in on what is the problem. If they come in with their arm backwards, does most of the other stuff really matter? Not necessarily.

Every chance you see them talk to them is a chance to assess them. Were they talking perfectly before and not so well now? Is their skin now diaphoretic and pale. IS their breathing now severely labored when it wasnt before.

ER was a whole different animal to me as I had worked on the floor. You are worried about such different things up there and you can tell when you call to give report to the floor nurses because I will tell you what you need to know, and thats the facts, you can do the rest up there.

Dpeterson777 · Sep 3, 2012

I am also starting as a new grad in ER next week! This is so exciting! I am nervous about starting in ER but am looking forward to it. I always liked ER from volunteering there and during clinicals. I think we will learn SO much this next year. Good luck to everyone, lets share stories of how much we learn once we start : )

FLmed · Sep 3, 2012

Oh please people do this! I had a critical patient come in who was on the verge of crumping the other night and when we hooked him up to the 3 lead it showed asystole. Of course this got the attention of everyone around and they came running. I told them to back off look, he is awake, talking and moving around. Lets get a stat 12 lead and go from there.
The key with ER is focused. You have to focus in on what is the problem. If they come in with their arm backwards, does most of the other stuff really matter? Not necessarily.
Every chance you see them talk to them is a chance to assess them. Were they talking perfectly before and not so well now? Is their skin now diaphoretic and pale. IS their breathing now severely labored when it wasnt before.
ER was a whole different animal to me as I had worked on the floor. You are worried about such different things up there and you can tell when you call to give report to the floor nurses because I will tell you what you need to know, and thats the facts, you can do the rest up there.

Love what you wrote! Every interaction is turned into an assessment! :-)