Would appriciate advice to a new ER RN

thelema13 · Feb 1, 2012

Speed = prioritization. Take care of the sickest ones first. Recheck the charts for new orders every 10-15 minutes. If you are expecting something (labs, EKG, ABG, etc.) then I always do it, based upon my experience. If orders haven't been put in, I ask the doc and put in a VORB. If you ask you shall receive....

Delegation: sounds like that one aide has good chemistry with you. If your techs are hiding, lazy, whatever, talk to them personally, if that doesn't work, your charge or supervisor. Lazy techs = no bueno. Sometimes it gets busy and you have to remind them "Now it is time to work..."

Codes: I work in a 32 bed ED in the heart of Florida, aka Retirementville. Our average age of the town population is >75, of admitted pts is >65. I have worked numerous codes, and I am still not 100% comfortable. Team duties should be assigned, or volunteer for a task (lines/labs, meds, scribe, compressions, etc.) You will get it down, I still brainfart from time to time on the baddddd codes. You can't do it all, it is a team effort. Take a duty you are comfortable with. I know if I can start a line on an hypovolemic shock code, I can start a line on anyone.

Good luck, you will get better, the ED will get better. You have plenty of experience, get into an ADD mindframe and you will blossom. Cheers!

TinyRNgrl · Feb 1, 2012

I am sure you are doing just fine. You have only been there a couple weeks. As long as you are prioritizing and making sure the critical tasks are getting done first, then rest assured the toothache pt can wait a few minutes for their meds.

I totally get what you are saying about the tech who is anticipating what is going to be needed and on the ball. A tech can make or break ya sometimes. And I always make sure I help them when I can and never abuse them or over delegate. I do as much as I can. The techs I work with know if I am delegating that I just don't have time.

Give yourself some time. ER is a tough place to be but is a very rewarding place. And you will feel more comfortable with your pace through time. It took me a good 6 months before I even started to feel confident in myself.

As far as your codes go. Again, I think through time you will feel not so "froze". Study up on your ACLS drugs. Review your algorhythms. But again, just like in ACLS, it is different when your in action. If time permits, sit down with a coworker afterwards and review stuff. Understanding WHY we are doing and pushing the things we did helps to put it all together and understand it better. Maybe your boss or preceptor can help answer the things your not sure about. A lot of our docs love to teach and never mind explaining things. Last night we had a trauma arrest come in. We ended up getting spontaneous pulses back and coded this pt for 45 minutes. Came in PEA. 1 EPI, got pulses back for about 13 minutes, went into v-fib, shocked x2, NSR with peak T waves, pushed calcium, pt went into Torsades and was in torsades for several minutes, pushed magnesium. Pt ended up going back into PEA eventually and we had exhauseted pretty much everything and called it. Total this pt had been given, Epi x2, atropine x2, amp of bicarb, calcium, magnesium, amiodarone, had a dopamine drip running, 1 unit of PRBC all while a chest tube was being placed and also establishing an IO in the proximal humerus because the lower extremities were completly mangled. Codes are very hectic......but you will get more comfortable and not so "deer in the headlight" with experience.

Give yourself time. And enjoy being an ER nurse. We are a rare breed.

Nire83 · Feb 1, 2012

1) Speed: Go in and say hi to your pt, QUICK focused assessment. Wait for the orders then go back in and do EVERYTHING. IV, meds, fluids...etc at the same time.

2) Delegating: Just speak up and when you know something is coming in tell the techs what you need. Our techs do a lot of blood draws (if im not starting an IV, or couldnt get labs), EKGs, urines, ambulating, meal ordering, paging for xray etc... When an ambulance is coming in i will say "We have a chest pain coming in, can you please grab the EKG machine, get vitals and hook the pt up to the monitor." Again, get EVERYTHING done in one trip to the room. Its a pain but i will often grab another nurse too if i know i have a very sick patient coming in and i need to get a line (or 2) in, labs done, an EKG, foley placed..etc..etc. If you are drowning tell your charge nurse, thats what they are there for.

3) This may be a facility issue - our codes (and yours) should be very organized. Someone on meds/tasks, someone on monitor, someone documenting. If we know a trauma/arrest is coming its important for someone to speak up and say "Who is doing what?" If my patient in a room codes i will scream "I NEED HELP IN HERE" and just start with the ABC's - just get chest compressions going ASAP. BLS first.

Good luck - it takes time but just lean on your other co-workers and be sure to be there for them when they are having a heavy pt load day too!

Nire83 · Feb 1, 2012

Oh - i forgot to add some stuff!

Do you have order sets that you can order? If an abd pain is coming in i will order a bunch of things to get the pt going so during the first quick hello i'll get a line put in and labs done, ask the pt to give a urine sample and then ask the tech to pick it up and dip it when the pt is done. I'll draw several tubes to be spun so unless something special needs to be ordered i will basically have all the blood for any add on tests the doctor orders.

KalipsoRed21, BSN, RN · Feb 3, 2012

Thanks for all the replies so far. Thanks NIRE83 for your detailed response. I'll try the "HI" and then come back after orders thing. We do have order sets but they are ordered by the triage RN and I'm not allowed to triage for at least a year. I do try to anticipate what orders I'll have and get everything I can from the patient before the MD orders those samples.

I've 'started' codes before. I don't have such a problem with starting CPR and basic BLS...I've had quite a bit of practice at that. What is different is that on the floor I'd do CPR on my patient until the code team got there and then they'd just take over....I mean charting and everything. I wouldn't leave just so I could answer questions about my patient, but it was all taken out of my hands after the code team got there. Now I'm in the ER and actually suppose to participate in the code (ie push meds, chart, etc) and I'm having a hard time transitioning past basic BLS and into ACLS. Probably because BLS is my comfort zone and I've done it...I've never done ACLS aside from taking the class.

Also, I have noticed that code situations at my hospital are not the organized chaos they should be. I had the privilage to be a nurse's aid in a level 1 trauma center for 4 years prior to being a nurse. I've see what true organized chaos can do for a patient and it is very awesome. My current hospital is very tiny and the couple of times I've mentioned that the codes seem a little disorganized (in a totally innocent and respectful manner) I get told that chaos in codes is normal. This is true, but not if you know what I mean, but I don't really feel comfortable pushing much more because I'm new to the ER

BelgianRN · Feb 3, 2012

I'll stick to commenting on the codes mostlly as I work in an ICU and not an ER. We do a vast amount of codes and I'm one of the lucky teachers for our new nurses (generally referred to as chicklets and other charming nicknames...).

Generally what I found works well when learning codes is to ask for a certain role. E.g. I'll generally assign one of the newer nurses to observe first followed by chest compressions/bagging after one or more codes. I think that is the part that you have already covered. Then I'll generally try to get them to get somewhat comfortable on the differrent stations during a code. Make them the monitor/defib station then airway management, followed by charting and finally followed by anticipating/pushing meds. And I always tell my chicklets when anticipating a possible code to remind the one that's going to lead or the charge nurse that they prefer position X because that's where they are learning and focussing on now. Generally they'll get the preferred position and it reduces the deer in the headlights, or to keep in theme the chicklet and the fox...

So I would suggest just create your own structure even if others are creating chaos. Focus on the person leading the code and listen to his/her orders. I tend to "zone out" if too many people are talking at once or giving orders and just follow the person that makes sense and is leading. Ofcourse once you're working for a few years and you have earned respect you can generally ask for some silence and order but now you are still the new chicklet in the pecking order.

On orders for patients keep in mind that I have no idea of the inner workings of your ER. But in the ICU my golden rule is if a physician wants something done ASAP on a patient they'll have to tell me they prescribed XYZ or they'll have to tell someone else to tell me. If they don't then it's too bad I'll see it next time I'm checking the system for orders which in my ICU is once every two hours if the patient is/remains relatively stable, as I'm working on other things in between. I imagine the same things happen in the ER if you are busy with other more critical patients you can't hover over the chart until someone happens to prescribe something for that stable non critical case. You'll probably have your own system to check regularly for new orders on your patients and if something is prescribed in between and nobody felt the need to tell you, how were you supposed to know. Unless your sense of smell is extraordinary...

brainkandy87 · Feb 12, 2012

Prioritize, prioritize, prioritize. This involves knowing what the pt needs and will need (what's the presenting problem? abd pain? chest pain? know your basic set of things that need to be done), knowing what your docs expect to be done stat, and knowing what pts you need to take care of first. Yes, that patient in room 3 needs a bag of Levaquin started and was here first, but that patient in room 1 is dehydrated and hypotensive, they need those fluids hung stat.

Never panic. Tell yourself that. Do. Not. Panic. Trust me, in every code, basically everyone is nervous. It's a nerve wracking situation. You have someone's life in your hands. But remember, every code is teamwork. Everyone has their assignment. Yes, you need to know what's going on in the big picture, but focus on what your assignment is. Even the MD needs to stop and regroup every once in a while to make sure everything is running as it should. Keep your cool, focus on your job, and it will just come naturally.

Editorial Team / Moderator · Feb 12, 2012

Never panic. Tell yourself that. Do. Not. Panic.

Yes, this! :) I learned this back in the day as an EMT-B ... rule number one: it is not my emergency (i.e., you can't help anyone if you're freaking out). Breathe!

NO50FRANNY · Feb 12, 2012

Hey there,

I agree with all the comments so far. Some great advice I have been given over the years:

1) When the you know what hits the fan, like an arrest or battle stations, concentrate on slowing down your breathing (I actually still have to do this after many years). No-one will notice you taking deep slow breaths as you do your work. This will slow down your adrenaline dump and stop you from losing your fine motor skills.

2) ABC pain. Pain trumps everything after ABC, then other tasks can be carried out. I will usually assess a patient very briefly, vital signs while getting a story, and sort out their pain before carrying out any investigations / interventions. The rest is all anticipation- example-pt. with likely appendicitis, 5/10 pain- vital signs, straight to doctor for orders for analgesia, give analgesia, then line in, fluids up, write story, send bloods, get urine and so on.

3) When you get that deer in the headlights feeling, go back to A, airway etc. systematically. The organized chaos of codes is simply a bunch of people going through this in their head and carrying out tasks according to each function. Once you get past basic life support- A- what is the best airway at that moment- NP OP BV- Is someone doing that? no progression past A until A is sorted and move through the ABC's this way. In my facility, Team leader, and a nurse for each letter plus a runner. Remember, the patient is already dead, so the only way is up.

4) As best you can (after ABC pain of course) try to do everything from a nursing perspective that you think a patient will need one patient at a time. I mean everything- including explaining to your patient what investigations are likely and how long they can expect to be in your care. Patients are less anxious if the have a good idea of what will happen to them during their stay and how long they can expect to wait for us to carry out our investigations and why. This saves a lot of running back and forth, questions from the patient and their family, and docs chasing you for things.

Hope this helps.