shifting priorities

[blueinplaid]

I am relatively new to the ED, and am working on organizing my time/priorities and am curious to hear how others do it. For instance, let's say I get patient A, a chest pain with a positive history, has had two ntg, an IV, and NTP placed to chest en route via EMS; pressure is now a 4/10. While I am converting his IV to ours/attempting to draw labs from said site, the tech is getting the ekg etc. Dr. orders aspirin and metoprolol. i send the labs off, but before I can give him his meds, i get patient B who also has similar history, no ntg, no paste, (chest pain obviously), but is getting an EKG. Neither EKG shows acute abnormalities. Now, my question is, do i finish with patient A, or do i check B, assess his pain for myself, give him his aspirin, ntg, etc. I run ito this frequently. i find myself going to patient B to try to give him some relief with ntg, but that means Patient A is suffering without being completed.....i suppose i should complete patient A? I am guessing that maybe i should take a minute or two to read the triage report more thoroughly and make a quick decision that way, or go into the room?

It's the shifting of priorities that I struggle with, but also the reason why I enjoy the challenge of the ED dept.

It's hard to stay focused!

:monkeydance:

Comments appreciatede!

[ERRNTraveler, RN]

I would see pt. B quick,assess him, get his labs drawn, give him the aspirin & nitro, then go back to pt. A to finish up giving the rest of his meds. This way, you will not delay seeing and assessing the new patient, and you can get his blood drawn right away so as not to delay the cardiac enzymes.....

[NurseCherlove]

I too would go to assess patient B, get labs, and medicate before going back to patient A in this instance since patient A has at least already gotten some NTG on board and his CP/pressure seems to be decreasing.

While it is different from ER, I am constantly having to "shift my priorities" in M/S and believe me, we do get quite a few acute problems that arise - it's just lovely when there's something acute going on with 2-3 of your 6 patients and there are about 5 other things that you should have done 5 minutes ago...

[RunnerRN, BSN, RN]

A few things enter my mind.....first, is there anyone available to help? If not, then think of it this way - first pt has an airway, is breathing, and has an IV. He is not crumping, his pressure has been relieved w Nitro (so you have a higher index of suspicion that this is true angina), and the doc has seen his EKG. Second pt has an airway, is breathing, does not have an EKG, has not had any interventions to help his pain. For pt A, metoprolol and aspirin are not going to acutely change things (unless his HR/BP are off the charts). I would go to pt B, start my IV, then give a NTG if ordered by the doc (our CP protocol does not include nursing giving NTG before being seen by MD). That way, both pts have their ABCs covered.

I'm sure you know this, but never give NTG without a good IV line. Otherwise, you run the risk of dropping someone's pressure so greatly that you won't be able to get a line. I've actually seen a pt go asystole for 5 seconds after a NTG was given.

Anyway, if you trust your EKG reading skills and the ER MD, you can also triage in your head accordingly....pt A has some PVCs but nothing else, pt B has some ST depression. Obviously, you priority has just become pt B.

Hope this helps!

[bigsyis]

I would see pt. B quick,assess him, get his labs drawn, give him the aspirin & nitro, then go back to pt. A to finish up giving the rest of his meds. This way, you will not delay seeing and assessing the new patient, and you can get his blood drawn right away so as not to delay the cardiac enzymes.....

My thoughts exactly.

[phillyrn10]

Interesting that you mentioned having access (and saline ready to go) before giving nitro....I do likewise. But I often have people say "well the patient carries nitro and takes it at home" ...............of course, I'm not responsible for them when they're home.

[phiposurde]

I believe there not just one answer, it depends. I guess if we would have to come with basic rule:

1) Have a quick assessment( do they look sick vs none sick?)

2) always try to find ways to multi task and delegate task. ( Is there someone else that can do some of the job?) Make kind of a " grocery list" what need to be done and prioritizes it and delegate it.For example,at my center we have patient care attendant( PCA) they help with cpr, patient transport, etcetera. Well if I get 2 patient at the same time. I have a quick assessment of my patient then I go to the sickest. The other one , I would call a PCA to help get undress, hook to a monitor and in the mean time I call for an ECG. While all that is happening I do nursing stuff( medication, IV, reading the other ECG, taking HX).In that example the list is:the patient need to be undress to be assess, I need an ECG( MI vs angina or non STEMI), I need vitals before giving medication, need hx to evaluate. Put all that come with experience. It's like people talk about critical care thinking. Can you really describe it?? Not really after seeing 40 cp your starting to know what you need or have to look for.

3) keep your ABC in mind. For example, this week we were waiting for a patient in the trauma room and suddenly one went bad in the hallway so he got rush back.4-5 nurses jump on him. They all went to cut clothes, hooking monitor, starting IV, getting BP. He had a snoring respiration. I had to maintain airway open. But no one really payed attention to it( tunnel vision). I find in those situation just before you get throw into adrenaline country taking 2-3 deep( even one if your rush) breath help me concentrating.

4) do not be afraid to stop think and talk to yourself. When I was in college, I was in a first aid team that did competition. I learn a great deal on priority, delegating and taking quick decision.

5) Don't spread to much. There more chance to forget things

I find it hard to explain how I take decision, but hope I was able bring some light a little bit. I could suggest you to practice at home.Make a list of your patient or the patient of some of your coworker. Write down the initial presentation, the EMS story, the vitals. Then play the "what if game?". What if patient A at arrive at the same time as patient B? What if C went bad while B arrive? Practice and try to rationalize what is needed and what can wait. But at the end the best decision to take is to go work in a hospital that as enough staff so you will not have tho make those choices !!!

[phiposurde]

let's say I get patient A, a chest pain with a positive history, has had two ntg, an IV, and NTP placed to chest en route via EMS; pressure is now a 4/10. While I am converting his IV to ours/attempting to draw labs from said site, the tech is getting the ekg etc. Dr. orders aspirin and metoprolol. i send the labs off, but before I can give him his meds, i get patient B who also has similar history, no ntg, no paste, (chest pain obviously), but is getting an EKG.

*** Get B hook on monitor, run automatic BP. While the BP is running I.m going to get my meds for A ready and bring some NTG, ASA to bedside of B since I'm in the med room. Come Back to B bedside leave med. Bp normal. Give Meds ASA + first dose metropolol( I presume 5 mg IV x3 q15 min). Put BP machine on q15 automatic. Now I have 15 minutes to go see B.****

Neither EKG shows acute abnormalities.

**** 15 minutes later I go back to bed A give 2nd Dose of metropolol if appropriate. Return to B. If MD saw follow orders for the next 15 minutes. Just before I leave to go to med room for B( if required) I go check patient C( we have 3 patient on monitor assignment). press on automatic BP while I go. Now I'm on my 15 minute before 3th dose of metropolol and 2-3 minutes the BP cuff take for patient C. By the time I come back to patient B bedside, I have a pressure for C which I do a quick note. Go check patient A then concentrate on B.

Then I start

bitching that nobody is helping me!!!

[blueinplaid]

Thanks to everyone's response. I have been seeing pt B and then finishing A, but I don't think I stopped to think about the exact physiology behind it, just sort of instinctively knew. Stopping to think is hard for me when time is of the essense! I am learning and growing every day in my nursing career!

[48RVRN]

LOL Ain't ER fun!!!