EDRN10

Use the search button. There is tons of great info on this site you just have to look. This is a reply I had given to someone who asked nearly the exact same question. ER nursing has many rewards along with many down falls here's a few that I have experinced in my time working in the ER. The Good: 1. Challenging work environment requiring many different nursing skills from ICU patients to minor complaints, from birth to death we see it all. 2. Instant satisfaction. Example would be someone is in severe pain from a broken bone. We give them pain meds and a splint and they are feeling much better. You may have the same patient for days or weeks in an inpatient setting with no change or improvement. Generally in the ER people are feeling at least somewhat better by the time they leave. 3. Chances to actually save a life. You will help take care of patients that you know had you and your team not intervened in a timely manner that the patient could have died. While this is possible in any area of nursing I would say that it is more likely to occur in an ER or ICU setting. 4. Fast paced work. There is rarely a dull moment and almost always work to be done. The Bad: 1. Fast pace can become overwhelming at times and is not for people who have trouble prioritizing what needs to be done. 2. Many people abuse the ER and bog down the system for minor complaints that could be handled at a family doctor or urgent care that do not need to be in the ER. This occurs for a variety of reasons from lack of education, lack of insurance, and many more but, my least favorite "I got a medical card so it don't matter where I go because I don't have to pay." This can become very frustrating at times. Many days these are primarily the people you will take care of. 3. High stress more so than anywhere else in nursing I have encountered in my limited experiences. When you have a CVA in one room, a MI in the next and your getting an ambulance in another bed this can become very stressful. Must have good stress management skills or you will have trouble in the ER. There are many many more aspects to ER nursing but these are a few I can think of off of the top of m head. I'm sure some of the more experienced nurses can chime in with some more good and bad of working in the ER.

I would say our average wait time is 60minutes or less. Worst I have seen at our ED is 30 people waiting in the lobby with the longest wait time being around 4-5hr mark. We average right around 180-225 pts a day. Really busy days for us is 275+ patients. Primary reason we achieve such a fast turn around is nearly all of our MD's are paid by the patient. So seeing more patients means more money for them.

1. Today I actually helped save a life. 2. To the person in the next room that did not get their pillow when the pressed their call button and asked for one. "I'm sorry I was not able to get your pillow as soon as you asked for one. I did not realize it was more important for you to get your pillow than the patient in the next room over to get a potently life saving/stabilizing medication." 3. Don't tell me you body part such as you arm is completely numb and in the same sentence tell me that the same body part hurts 10/10. 4. No you cannot take an antibiotic for the flu/virus. It will not help. 5. If your stupid enough to smoke while wearing oxygen at home then I have no sympathy for the facial burn you just received. 6. I am not your waiter. I will not bring you endless supplies of food and drink during your stay in the ED. If you want something to eat or drink then you are feeling better than all the patients that need to be in the ED and you should go home.

Sorry was not intentional just trying to defend my position. Now to move on I had an awesome pt last week. Pt is in their 70's but appears to be a very healthy and lean individual, comes in by EMS with complaints of dizziness and back pain. Pt's skin color is extremely pale. Symptoms started approx 1hr prior to arrival. EMS reports pts b/p is 80s/50s and they started an IV and was giving fluid bolus. Began to triage pt and placed them on automatic b/p cuff. Cuff wont read. So I attempt a manual and all I hear is the systolic thump and nothing else it is 78. Right now I'm thinking something is not right. I run out and grab an EKG even before triage is finished. Run the EKG shows NSR. Take the EKG to the doc and tell them to please come see this pt ASAP. I go back in the room, lay the pt flat and place auto b/p cuff back on pt and it finally reads 105/56. Doc comes in the room and begin to assess the pt and as she does feels the pt's abdomen and gets a strange look on her face and tells me to get this pt to CT now. Doc has the secretary paging CT to come get the pt as I start as second IV and draw labs. I grabbed the biggest IV in our IV cart because of the frantic look on the docs face which is a 14g and pt did not even flinch. CT tech arrives and I go with the pt to CT as the doc wants them on telemetry. We do a CT abdomen/pelvis on the pt with contrast and as the scan is running I hear the CT tech who is very experienced state "oh ****." Pt has a ruptured AAA on the scan. I tell the CT tech to make sure the radiologist reads this scan right now and I call the ED MD before leaving CT and tell her that the CT tech thinks the pt has a ruptured AAA. We get the pt back in the ED and by that time the ed doc has already paged the vascular surgeon and they are on their way down. By this time first set of labs are coming back and pt's hgb is 10.0 and b/p is starting to drop so I place pt in trendelenburg. Vascular MD gets to the ED and tells the pt that he has a ruptured AAA and that he is going to surgery. We pressure bag in 1L NS and give the pt 2 units of blood as the vascular MD inserts a central line. Pt's b/p is still dropping is now 60s/40s but pt is still alert and talking to us. Vascular MD finishes up the line and we rush the pt to the OR. As soon as we get there repeat labs are drawn and pt and pts b/p had dropped even more and is now 52/30. I stay with the pt until the vascular MD opens them up and was able to see the massive amount of blood pour out of the pt's abdomen. As I walk out I hear one of them say that the pt's repeat hgb was 7.5 when they first arrived in the OR after the 2 units of blood given in the ED. Pt miraculously makes it through surgery I find out later that day. 6 days later I see the vascular surgeon in the ED and he tells me he just d/c'ed the pt that morning and he had been up walking around without assistance for the past 2 days. Also turns out pt works as a delivery driver and was out driving a route when EMS picked him up. One of the people at his regular stops noticed the pt stumbling as his walked and his skin color off and called EMS for the pt. This was one lucky pt.

I think you will do fine and gain a lot of valuable experience. Do not get hung up on the trauma level rankings. I work in a ER that is not a trauma center and we see tons of trauma's. You have to realize that any traumatic injuries that occur and people just come in through the lobby you will see which will be more than you think. Also if a pt is severely injured and not stable enough to transfer to a higher trauma center and your ER is the closest they will come to you. You will do a lot of work to quickly stabilize the pt for transfer to a higher level facility. Even in a trauma center most of your patients are not going to be trauma patients. With all that being said every ER is different but all have the opportunity to see any thing from a stubbed toe to a major traumatic injury.

I started in the ER as a new inexperienced RN. However I did have approx 6months of ER experience working in a student position in the ER. I personally don't think you can go wrong in either place as both will offer lots of unique experiences for you to learn and grow as a nurse. If you think you want to do ER before you make up your mind I would highly recommend at least job shadowing for a few shifts first. Ask which days of the week are typically the busiest and try to job shadow on those days. ER is not for everyone so try to make sure its going to be a good fit for you. Also make sure the ER offers a good training program for new nurses. Mine offered 4wks of classes along with 8wks of preceptorship that I felt was a big help in easing the transition into the RN role in the ER. Good luck in where ever you end up.

As I stated previously I did not suspect poor care in this instance from the nsg home. In this particular case the nursing home if i remember correctly had not addressed the confusion as the symptoms onset had been fairly recent (ie less than 24hrs) and they felt it was warranted to have the pt sent to the ED. While I agree with you that 24hrs in a nsg home setting is a short amount of time, however in this particular case had the symptoms been going on for more than 24hrs I most certainly would has suspected poor care. If a patient had unstable vital signs and stroke like symptoms for greater than 24hrs wouldn't you?

I didnt suspect it at the time and still don't considering his symptoms at the time. I cannot remember how long the patient had the worsening confusion, but had it been more than 24hrs I'd would suspect poor care or lack of attention to the pt at the nsg home.

Congrats. Glad to hear all went well.

Had a good one last wk. Pt came from nsg home hx of dementia complaining of being more confused and low b/p. Pt initial b/p was 70/50. Bolus-ed the pt with no rise in pressure. Pt placed on dopamine drip and pressure slowly came up. In the meantime, ekg, labs, foley, x-ray, and head CT were all performed. Labs started coming back and everything was abnormal. EKG was normal but triponin was elevated. Renal function was crap. CT showed a bleed. On top of it all pt had a UTI. So NSTEMI, Acute Renal Failure, CVA and UTI all occurring at once. One of the sickest patients I've seen in a while for sure.

ER nursing has many rewards along with many down falls here's a few that I have experinced in my time working in the ER. The Good: 1. Challenging work environment requiring many different nursing skills from ICU patients to minor complaints, from birth to death we see it all. 2. Instant satisfaction. Example would be someone is in severe pain from a broken bone. We give them pain meds and a splint and they are feeling much better. You may have the same patient for days or weeks in an inpatient setting with no change or improvement. Generally in the ER people are feeling at least somewhat better by the time they leave. 3. Chances to actually save a life. You will help take care of patients that you know had you and your team not intervened in a timely manner that the patient could have died. While this is possible in any area of nursing I would say that it is more likely to occur in an ER or ICU setting. 4. Fast paced work. There is rarely a dull moment and almost always work to be done. The Bad: 1. Fast pace can become overwhelming at times and is not for people who have trouble prioritizing what needs to be done. 2. Many people abuse the ER and bog down the system for minor complaints that could be handled at a family doctor or urgent care that do not need to be in the ER. This occurs for a variety of reasons from lack of education, lack of insurance, and many more but, my least favorite "I got a medical card so it don't matter where I go because I don't have to pay." This can become very frustrating at times. Many days these are primarily the people you will take care of. 3. High stress more so than anywhere else in nursing I have encountered in my limited experiences. When you have a CVA in one room, a MI in the next and your getting an ambulance in another bed this can become very stressful. Must have good stress management skills or you will have trouble in the ER. There are many many more aspects to ER nursing but these are a few I can think of off of the top of m head. I'm sure some of the more experienced nurses can chime in with some more good and bad of working in the ER.

First off take a slow deep breath as all will be okay. I was placed in a somewhat similar situation all thought not quite as time constrained as yours prior to taking TNCC. Yes you are correct in the focus of TNCC being your ABC's and DEF and so on. There are also areas in it referring to burn nursing. However TNCC focuses on the initial assessment of the patient as if they just arrived to the hospital. Make sure as you go down the ABC's make sure you address all possible issues with each letter before you move. An example would be pt is not breathing. SO you would begin to bag the pt if this is available and then reassess pts breathing. Upon reassessment if pt is still not breathing then you must continue to address the issue of breathing until the issue is resolved or another team member such as RT is able to take over bagging the pt o pt is on a ventilator. Once this is completed and pt is either breathing or we are breathing for them then you can move on to letter C and so on. Another area that was emphasized in my TNCC class was to physically touch the pt as you examine them and of course to remove all clothing. The idea behind the touch is pt's may not realize they are injured in a area until you touch it. Also if you cannot see body of the pt then you cannot fully assess them. These were all the big take home points i took from TNCC. As far as the test goes it is just like all nursing exams. There are multiple correct answers but you must pick the best one. Just remember to follow the ABC's and you should be fine. Plus if your TNCC course is a 2 day one like mine just make sure you pay attention to the things that the instructors seem to place a lot of emphasis on as these are likely things that will be on the exam. Hope this helps you some.

ESME- That works sometimes so long as they haven't OD'd and are unconscious. Depending on you facility but our ED lets RN's pt lines in EJ's. IV drug users usually resort to shooting up there after all other veins have failed, so unless you get a hardcore user you can usually get an EJ. If they are gone then it's time for a central line in my experiences at least.

If your having trouble getting a large bore IV in a critical pt with low b/p I have found one trick that has helped at times. If possible start a small IV in the hand or wrist and hang NS on it. Place a turniqutte on the pt and let the NS run wide open may even need to apply slight pressure. If all works correctly the veins in the upper forearm and AC area should start to rise up as they fill with NS and make then easier to get into. I've done this a couple times on pt's by starting a 24g in the hand because we could not get anything else. After applying the NS the veins popped up and I've gotten 14's and 16's in the AC. just be aware that you may not get a blood return and may actually have NS running out of the IV you just stuck. It was really bizarre the first time I saw it. Anyway just my two cents.

Our ED does not have a system so basically all vital signs are left up to nursing judgement unless a md instructs something specific. This is an okay system so long as all your nurses know what they are doing, but as I am sure most places are we have nurses that just don't seem like they have a clue sometimes. I know I personally do vitals q30-60mins on most regular pt's, minor stuff I get vital's at triage and d/c, and critical pt's I do vitals q15mins or less. I'm going to keep checking back to see what you find out lunahrn because we really need a system in our ED. EDRN10