needsmore$

And give them an empty very large 3 ring binder. I print out info about what we're caring for. I use 'up to date' alot. I highlight the important stuff and before they know it, they have made their own ED reference book

And a side note Do not let other staff dictate the type of patients you get. (if possible) I have had many charge nurses give me the "more complicated" stuff right off the bat because "this is a good one for her/him". If you don't build the foundation then the "good stuff or the "interesting" won't make sense. I know many times you get what comes in the door but it takes a preceptor twicew as long to do what needs to be done... explanations, etc. If you are able to take a few weeks to get the lesser acuity stuff to start, then when you get the level 2s and 1s, it makes sense

Where to start.... I have been precepting for 25 years or so. I find that to start, I just have the new associate work with me to watch what I do. Then we talk about the critical thinking that ED nurses do in all aspects of our care...from where we put IVs to the why's. I stresss the recognition of "sick" vs "non sick" appearance and always plan for the worst case scenario and how to rule out things using assessments and history taking. I go over the A-B-C method of assess and intervention of all patients. When ready and the new asociate has learned "my routine"-- I start by giving her 1 patient-- usually a level 3 or 4 ESI acuity. They focus on assessing and learning how to document their findings. I take care of the tasks of IVs, etc until they are proficient at the nursing assessment stuff, and then we add the IVs, etc. ENA has orientation modules as well that cover soup to nuts of systems assessment. Good luck

I have been an ED nurse since 1986. And yes, I still love it. The days where I feel that I made a difference in someone's life...what a great feeling Yes, ED nursing has become more of a 'exacerbation of your chronic problem ' type of nursing about 80 % of the time, but those days where you know that you and your care turned a critical patient into a stable one, or you made someone who was terrified and in pain; relaxed and feeling better, ready to face whatever needs to be faced... The feeling that I HELPED someone, truly helped, boy it gives me a high to this day I'm not talking about the everyday care we deal with, but those times where your adrenalin is pumping just as fast as your norepi is dripping in...and someone that was swiling the drain now is stable.... That's ED nursing.

We don't hold the narc until the ride is here--but we do ask the patient who will drive them home so we can give it--and then we give it, and if/when the pt is discharged, we have them call for their ride. (or taxi) Similiar to procedural sedation--the ride doesn't have to be here on site until they're ready to be discharged.

I'm with the "consult the legal beagles" here and develop a policy that is clear cut. Our ED also is--'no ride, no narc' rule. And yes, we get the tricksters. If they leave, we document that they eloped from the ED (similiar to AMA)--usually without notifying staff I am working on updating our policies in our ED, and this is one I am working on--when is a patient considered 'incapicitated' --fro drugs, alcohol, where the ED staff CAN detain them using restraints (the overtly OD'd patient or drunk as a skunk) but, they are not 'involuntarily committed" (we call it a 302). It is a very grey area and I am finding that we need to be VERY specific regarding lab data results, patient behavior assesments, fall risk, etc when developing this

search "demerol metabolites" using google and you will get some good articles

www.paindr.com/meperidine%20guidelines.rtf try this--it's a great little article about how the metabolites build up and can lead to neurological issues. now that they have dilaudid, fentanyl-which doesn't seem to have these issues, it is becoming best practice to avoid demerol use and use these other pharmocologicals instead

syringe pumps are great as well-- you can set it to admin over a certain amt of time-- so-- compazine which is 1 mg/min and you want to take a few extra minutes? set it for 10 min reglan, the same i have seen reactions from compazine and reglan. often they are related to the rapidness of the infusion a minute is a long time. often, when we stand there pushing meds, you may think you're taking 2-3 minutes, but in a busy ed and someone who's vomiting all over, you might be pushing it faster than you think and how fast are flushing your int? there is med sitting in that tubing. yes, a small amt but silly to take 3 minutes to slowly push a med, then squirt in zip the flush we give our phenergan, reglan and compazine in a 50 ml bag and run it over about 10 min. if there is a fluid restriction issue--renal patient, chf, etc, then dilute to 5-10 ml and use a syring pump.

Tylenol. Especially in the teens-- The danger is--they get no SE....right away. So, they don't tell anybody. And then their liver's shot And in others--Tylenol is the hidden ingredient...all the different OTC stuff that teens can get--many have Tylenol in it. It all adds up Alcohol. And then various prescribed stuff that they may use themselves regularly--from SSRIs, to narcs Street drug--varies. We rarely get 'one' flavor per person --often it's a mixed bag of coke, heroin, etc...

I think 2 patients at this stage, is doing well--but what acuity are they? If you find that you get caught up with 2, then ask for preceptor to give you a 3rd--so you can improve time management and priority setting. What is the 'normal' pt-nurse assignment there-- 1 to 3, 1 to 4? I find time management one of the most difficult things to teach and one of the more difficult skills to master! If you're caught up then accompany the physician/practitioner when he/she does their history/physical exam. I learned tons this way and many love to teach as they go. You should meet weekly with your preceptor and set goals for that week for you to strive for. Then meet at the end of the week to review your status. This way, you can express what you feel you need more exposure to, and your preceptor can tell you where you're at... Review protocols. Make sure you understand the WHYs of the things you are ordering or doing. That helps drive your education I remember when I first started in the ED. We were just starting nurse-ordering protocols (this was in 1986 BTW). Abd pain-- ordered CBC. The ED doc once asked me (new kid) Why are you ordering this? To say "Well, that's the protocol" would have been incorrect. Make sure as you are doing, you know WHY you are doing it...

To me--"ER" means Emergency Room-- and for most of us-- we are more than a room! We are a unit that specializes in emergency care of the sick and injured Maybe we should be EU nurses!

Healthcare crisis and its impact on Emergency Nursing--wait times, immigration, financial impact on hospitals, etc

Thank you so much. I copied your link and response and emailed it to her. I also told her that allnurses.com has great resources for nurses

Hello. I was asked a question by a friend who will be sitting for her state board exam in Feb. Her question was about showing proof of ID Now--does first and last name must be identical on both forms? Here is her question -quoted: "I am scheduled to take the NCLEX on Feb. 11th. Pearson VUE says that first and last name must match approved i.d. Even though divorced, I still use my married last name and my maiden name is still on my driver's license. Have you ever heard of anyone being denied taking their NCLEX b/c both last names are listed even though they are not hyphened"? I asked her to contact her state board as well. It's been a few (ahem) decades since I sat first sat for the boards-back then everything had to match. Thanks for your help

It is my understanding (from our health infomatics and ED docs) that the regular seasonal flu had not yet hit our area so anyone with 'flu-like' sxs was probably experiencing h1n1 as this was the only flu in town--at least until the winter starts up when (in our area) we start getting hit with the 'flu' --mainly in December-Jan and Feb Many of the flu-tests are also giving out false negatives--testing seems to be a wash out unless your patient is in one of the high risk group The CDC has a great website with info about the h1n1 and the seasonal flu as well This is where our docs get and develop their guidelines and treatment plans from

We currently use Meditech for Order Entry, Lab/Rad results, PCI We will be switching from Codonix (our current system of ED charting) to Meditech in the New Year I, too, am interested in how Meditech is working out as a documentation tool for ED patient charting. It's the critical patients that require documentation almost simultaneously on different systems that worries me. When you have to switch from Cardiac to Resp to Neuro screens to document your initial assessment because you've gotten that obtunded hypotensive patient...seems like a lot of unnecessary and frustrating jumping around to be able to adequately describe your presenting assessment (at least in the test system I've seen with our facility) I hope there's a Free Text option for me...

Stevierae--your letter was perfect. I hope you don't mind but I would like to borrow it for use in our ED setting-- some of our docs want the ED nurses to PUSH Propofol for moderate sedation --not for pre-intubation but as a procedural sedation med. I feel like I am banging my head against a wall trying to get some of my colleagues to recognize the dangers of this practice Your letter was well thought out, and included many if not all of the points I have been trying to make, and stated more eloquently as well. I have been an ED nurse for 26 years, and I find that its the less experienced nurses who seem to think-- "no problem" regarding doing new procedures, administering meds that they have very limited experience with. They read it about in in their reference book and think they're competent Thank you again

we're seeing 10-15 flu-like sxs/day--again mostly the peds, young adult crowd if they meet the symptomology criteria, we're not even testing anymore--just 'assuming' it's flu the high risk group get the nasal washings but in all honesty, i've heard that this test has a high false neg result, so, if the patient is high risk, they get tamiflu scripts have you guys gotten the h1n1 flu shot yet? it hasn't been available here yet. i have to add that i get frustrated at times at the amount of people who come in to get tested--they're not that sick, they have low grade fever, sl uri sxs. i know i shouldn't get frustrated because they're worried about flu, but the amount is just killing our ed. any of your eds developed an off-site flu triage area to funnel the flu group out of your waiting room?

http://beavercute.blogetery.com/2008/01/19/nursing-process-for-health-promotion-using-kings-theory/ This is kind of what I'm getting at--that our assessments include pts' goals as well as we assess physiological systems

Our director wishes to add to our routine documentation--patient's specific goals on WHY they came to the ED. And then--after this is identified, to document how well we met thios goal. It's not really NPSG oriented--(of course we have our core measures stuff still), it's just an additional focus on what the patient wants to accomplish while they are in our care.. I'm looking on line to see if any other nursing units document this way and maybe explain it a bit more eloquently-- I'll see what I can find

Good afternoon colleagues. With the Joint Commission focusing on certain aspects of documentation, I was wondering how specifically any of you document patient goals for their ED visit. Do you free text -- do you have a nice pre-written documentation tool that you use? I am currently working to develop a documentation system that must include patient- goal setting. I certainly can put together a query that just says-- fill in the patient goal (s) and then another that asks if they were met---but I was hoping that some of you had great ideas or things that you use that I could utilize in OUR documentation Thanks for your help! Goals-- already suggested (pain, relief of symptoms, diagnosis of problem)-- Annie

Congratulations first off-well done Well- that makes me feel a bit better-- I have PALS, ENPC (used to be an instructor), CATN so good to know that someone with similiar background relied on their experiences-- Was it a similiar format to the CEN-- computerized, etc?

Our ED (which currently uses Codonix documentation) is switching to a Meditech-- EDM Client Server sourse. This necessitates the development of screens for the ED nursesb to use to document assessment, treatments, procedure assists, etc I am currently trying to develop a "Burn Assessment" screen-- more like a burn trauma assessment than a minor-- burn injury When you are presented with a burn victim-- What do YOU look for--so I can make sure I've included as many choices as possible. I have: sites involved, thickness, % BSA- (Rule of Nines or Land & Browder), Airway assessment (patent, facial burns, facial swelling, soot), breathing assessment (Clear, stridor, wheezing, decreased) Circulation assessment (normotensive, hypotensive, tachycardic, bradycardic) (these are quick down and dirty rel to the burn pt only-- not the full in depth systems exam that can be found under other main system head-toe assessment), Cause of burn, Urinary output monitoring. VS and wt are always documented under their own VS screen, IVs the same, meds will be incorporated via the MAR that the doctors use, as is PAIN Am a missing any red flags that I need to put in so nurses (who don't do alot of trauma/burn victims and many of our staff are new nurses in general)) will be aware of what else they need to monitor... Any one else using meditech/client server that have these screens developed that I could use as a reference? Thank you--

I know--it just opened for testing applications in Jan-- I am starting to see some "prep" courses now-so hopefully one may come by locally-- Scott DeBoers is holding some and he is excellent (His Peds-R-Us classes are superb) so I'll bet his prep class will be top notch too--Thank you