As many of you know, I am not an emergency department nurse. However, I receive many questions about emergency nursing. In going along with our “what do nurses do” series, Susan DuPont, fellow nurse blogger and emergency nurse, will go over what emergency nurses do!
Emergency departments come in all shapes and sizes, and Susan works in a very large and busy hospital. When her Level I Trauma Center Emergency Department is full, they are at 123 beds (which includes hall beds), and no one gets sent out of their ED… people are flown into them. She sees the sickest of the sick! So let’s see what it’s like to spend a shift in Susan’s nursing shoes…
What do emergency nurses do?
Let’s dive into what emergency nurses do. Click on any bullet point to jump to that section.
- Clocking in and starting your day with huddle
- Focused care and patient flow
- What is ER nurse report
- Initial assessment of ER patients
- Actual assessment of ER patients
- What is a Primary Assessment in the ER
- What is a Focused Assessment in the ER
- What is a Secondary Assessment in the ER
- Stages of caring for a patient in the ER
- Receiving patients in the ER
- Admitting a patient from the ER
- Monitoring patients in the ER
- Discharging Patients from the ER
- Power Hour
- Clocking Out for the day
- More Resources
Besides being awesome, we see and do some pretty crazy things.
And not coincidentally, when someone finds out that I am an ER nurse, they always say, “I bet you’ve seen some really crazy things.”
But that is not all my day consists of. Mostly, I am running around managing multiple patients with a sharp eye on picking out life-threatening conditions.Many nurses will tell you that they did not like the ER; it’s hectic, very fast paced, and nerve-racking… But it is also exciting, more autonomous, and builds confidence. Not everyday will be excitement, not every day will be heroics, and yes, I will admit, that sometimes I feel like my job is putting out the fires closest to my feet.
But I wouldn’t have it any other way.
Wanna know if you have what it takes to be an emergency room nurse? Let me show you what a typical day in the life of an ER nurse is like.
In the ER, we have new people coming onto shift every 4 hours. You have many different opportunities for which time you’d like your shift to be. You can work 3 twelve hour shifts a week, 2 twelves and 2 eights, 5 eights, and you can come in all around the clock.
Once you have clocked in, you will have huddle where the charge nurse and managers hand out assignments and cover the current state of the department. This typically includes how many patients are suicidal, restrained, critically ill, and what is happening in the resuscitation bays.
Resus Bay: A resuscitation bay, or “resus bay,” is a special room in the emergency department for the sickest patients and the most time-sensitive interventions. From traumas to medical mysteries, any type of patient can be cared for in the resus bay(source).
It is important to listen to this information because you may potentially be taking care of one of these patients, but also because those patients require extra hands so be prepared to help out a lot.
We typically have a ratio of 4-6 patients to one nurse, however, this is not the rule, rather the hope. In the ER you cannot, by law, turn away a patient who comes in the doors. On the floor, you can refuse to take any more patients. If we can’t move patients upstairs, the waiting room fills up. When patients are waiting in the waiting room, the nurses that are in triage are responsible for these patients. Depending on how many nurses are assigned to the triage area, will determine the ratio. If you have 2 triage nurses and 20 patients, your ratio will be 1:10, if your waiting room fills up with 50 patients, the nurse to patient ratio becomes 1:25. That can be scary, but the scariest part is that they are solely relying on your ability to assess them correctly because a physician doesn’t see patients in the waiting room.
This is why, when a patient has a ready bed upstairs on the floor, you need to make haste getting that patient to the floor so we can pull one of those 50 people in the waiting room into a room to be seen by a physician.
You will see anywhere from 10-30 patients in your shift. The ER is fast moving, you will not have a lot of time to get to know your patients well. Movement is vital in the ER, or patients get backed up in the waiting room.
It is important to know a little bit about everything to care for every type of patient. This is why floor nurses are vital to the health care system. For example, I know how to recognize the need for a chest tube, set up for insertion of the chest tube, troubleshoot the chest tube and then I hand over the patient to nurses who care for patients with chest tubes. I do not, however, know long-term care of chest tubes, nor have I ever pulled one out. This is a big difference in ER nursing versus floor nursing.
As an ER nurse, you will be trained to recognize life-threatening situations, stabilize them, then get that patient to the proper place where they will be cared for long-term. Everything in the ER is short-term and fast moving.
Having empty rooms in the ER is fairly rare. So if you have a patient assignment, you will be full capacity all the time. But not all nurses will have a specific assignment. From the time a patient comes into the ER, they will pass through many nurses.
- A screener nurse will quickly assess their airway, breathing and circulation (ABC’s) and chief complaint then determine if the patient is able to wait to get a full triage or if they need to be seen immediately and go to the Trauma or Resuscitation Bays.
- The triage nurse will gather a story, get vital signs, screen the patient for potential infectious diseases, potential abuse, review history and meds, etc. then order any testing that the patient is going to need.
- Hand injury gets an x-ray
- Chest pain gets an ECG and blood work
- Then you have nurses that have a room assignment. These nurses will carry out physician orders and coordinate the patient’s care.
- Finally, you have nurses that are dedicated to Trauma and/or Resuscitation bays where the sickest patients get immediate medical attention. These are usually a one patient to one nurse ratio.
This is a very different kind of report than what you probably get anywhere else. It consists of pertinent information and a plan of care.
Pertinent information is vastly different in the ER than it is on the floor. We do not cover things such as IV access, treatment team members, allergies, ability to get up to the bathroom, etc. unless it is pertinent to the patient.
Couldn’t get IV access and needs IV access?…This.is.pertinent.
Does the patient have diarrhea and is quadriplegic?… This.is.pertinent.
Now, if a patient had a laceration repair and is going to be discharged home?… I do not need to know they are allergic to everything but Dilaudid because this.is.not.pertinent.
Giving pertinent information leaves out a lot of information that can be easily looked up or assessed if you really need to know it, but there is a very good reason for this type of report. It helps the oncoming nurse remember everything that was said and quickly triage each patient so they know who to see first. On the floor, you will likely get stable patients, in the ER, you get more variation on stability. If you think about it, we take care of the patients who are going to the med-surg floor along with the patients who are going to the ICU, cath lab, and OR, along with the patients that we haven’t figured out if they are sick or not.
When talking about the plan of care, it often includes, performing tests (labs, imaging, etc) and/or waiting for results to come up with a plan of care. If tests have already resulted then the team needs to either discharge, admit or monitor.
Here is an example of getting report in the ER:
“Room 1 is here with chest pain and a significant cardiac history. His initial EKG showed a long QTc and he has had 5 runs of V-tach with the longest run being 2 minutes. He received a bolus of 300mg Amiodarone and is now on an Amio drip. He also received 2 grams of mag and has been normal sinus rhythm with a normal QTc. We are waiting on Cardiology to come see the patient.
Room 2 is here with a small bowel obstruction. She has an NG tube already placed and is on low intermittent suction. She is admitted and waiting for a ready bed upstairs. She has been hypertensive that has been controlled with pain meds. Last BP was 130/85.
Room 3 just got here, they are complaining of right flank pain, I haven’t gotten blood work yet, they are in the bathroom getting you a urine sample, and a provider still needs to see the patient.
Room 4 is here with nausea and vomiting. They have received 2 liters of normal saline, 8 mg of zofran and need a PO challenge in an hour. They will be discharged if they can tolerate the PO challenge.”
No matter what, every patient you see will need to have an assessment done on them. However, the most important part of emergency nursing is which patient you’ll see first. This is a skill that takes time to learn and is carried out with a lot of teamwork.
I like to go into all my patients’ rooms and introduce myself, grab a set of vitals, do an ABC assessment and quickly review the plan of care. This should take no longer than 30 minutes to see all the patients. It is not a full assessment, rather it is to make sure that you have laid eyes on all your patients and can make your own judgment on who to see first.
Initially you decide who to see first based off of report, but then you lay eyes on all your patients and make that determination yourself. It is not that I don’t trust the judgment of my colleagues, rather I cannot go to court and explain, “I didn’t go see that patient for 45 minutes because the previous nurse said they were stable.” (We mentioned that in our previous post in this series from the ICU Nurse perspective.)
Your name is legally assigned to their care, you are responsible, you better be able to explain your actions and it cannot be based on someone else’s opinion. Especially in the ER where patients can become unstable very quickly.
Here is an example of me initially seeing a patient:
“Hello, my name is Susan, I have taken over as your nurse. I was told in report that we are waiting on lab results, as soon as the results come in, I will let you know. Do you have any questions?”
While I am talking to them, I am hooking them up to the monitor for continuous vital signs if they are not already hooked up. I update the whiteboard with my name, make sure they have their call light and as long as their ABCs are intact, and then I move on to the next patient.
I will then sit down at the computer and start compiling a to-do list. I order that to-do list based on timing, importance, and patient condition. If a patient has a breathing treatment due and another patient has IV antibiotics due, I will get both medications, go to the patient who needs a breathing treatment first (ABC’s!), grab a spirometer reading, start the breathing treatment and then go hang the antibiotics. After hanging the antibiotics, I will swing back and grab a post-treatment spirometer reading.
Now, I mentioned that I hook almost everyone up to the monitor. Some people say that is excessive, I say that is working smarter, not harder. To each their own. But, I will say that the patient who got a breathing treatment will need to have their pulse ox and heart monitored and the patient who got IV antibiotics should be monitored for a reaction, thus having them on the monitor will alarm you if something is going awry.
(As always however, follow your policies and procedures at your facility regarding monitoring!)
Once I have made sure that all my patients are stable and have any time-sensitive tasks performed, I do my own full assessment of each patient.
Now, this is not like a head to toe assessment on the floor, rather I look at each body system and eliminate issues that are concerning and acute.
The bruise on their leg from tripping a week ago? Not really important to focus on.
The open laceration on their arm from broken glass? Important to chart details on.
Every single patient needs to have cardiac, respiratory and neuro exam at a very minimum. If a patient is here for altered mental status, I do a detailed neuro exam. If they are here for chest pain, I do detailed cardiac and respiratory exams.
A good example of an assessment in the ER versus the floor is bowel movements. In the ER it is pertinent to ask if there has been any change in their normal bowel movements. If there has been a change a more detailed assessment needs to be performed. On the floor, it is pertinent to ask when the last bowel movement was, even if they haven’t had any changes in their bowel movements because on the floor you will be with the patient long enough to track their bowel movements.
In the ER you are trying to find out what has changed in their life to make them come to be seen. Spending time with a chest pain patient on if they have pooped today is not only time consuming, but it delays potential immediate life-saving care they should be receiving. They could be having a heart attack and time is tissue! Now if the patient is here for abdominal pain, you will ask when the last time is that they pooped. It is not the same assessment for every patient.
It needs to be said that if you come across something concerning during your assessment, you stop the assessment and get a physician. If I am doing a neuro exam and the patient is having facial drooping and slurred speech, I don’t continue with my assessment by asking them when their last bowel movement was. I get help. Time is tissue. If this patient is having a stroke, we don’t have time to assess further, I need to get this patient to the CT scanner and have a physician see the patient immediately.
If the patient is having a stroke, the best place for them is with nurses and doctors who specialize in caring for stroke patients. ER nurses specialize in recognizing life-threatening conditions, while floor, stepdown and critical care nurses specialize in the care of those patients. Often times, you may have had the patient for an hour before they are assigned a bed in the neuro ICU and all you know is they had facial droop, slurred speech, CT was negative for a bleed and they received tPA. You have done the first neuro exam and they are going to the unit. This can make giving report difficult. There will be a lot of questions you don’t know the answer to.
As an emergency nurse, you need to understand that there are limitations in place for patient safety and the floor nurses are just trying to keep your patient safe, so give them a break. And floor nurses give the ER nurses a break, they are standing in a pit of fire trying to keep the patients in the ER safe.
A primary assessment includes neuro, cardiac, and respiratory. This is done on every single patient no matter what they came into the ER for. The following is a list of basic assessments you will do on a patient in the ER. You will do a more detailed assessment if the situation warrants.
- Neuro assessment
- Orientation status
- Facial symmetry
- Motor movements
- Cranial nerve assessments
- Cardiac assessment
- Heart sounds
- Capillary refill
- Skin perfusion (pink, warm, dry?)
- Chest rise and fall/symmetry
- Breath sounds
- Breathing effort
- Oxygen saturation (pulse ox)
- Skin color
- Neuro assessment
This is the ER nurses bread and butter. You must be able to recognize when to dive deeper into a particular assessment and what to ask or be looking for. There are many chief complaints that you will come across and it is your job to ask the right questions.
For example: a 65 year old female presents to the ER with complaint of epigastric pain. She has been nauseous and feeling dizzy.
This patient will likely get a cardiac workup along with a GI workup and you need to focus the majority of the assessment there.
Secondary assessments are not always performed. These are case by case assessments. I personally try to do a secondary assessment on every patient I see, but sometimes it is just not possible. Secondary assessments include everything that is not in the primary or focused assessments.
You will either be receiving new patients, getting all testing done on patients, admitting patients, monitoring patients, or discharging patients. Any of these stages can happen at any time and you will likely have multiple patients in different stages throughout your day.
When I receive a patient in the ER, assuming the ABC’s are intact, I gather their story and discern a chief complaint. After reviewing their history, meds and getting vital signs, I assign the patient a level of urgency. Each ER has a different triage process but generally speaking patients are assigned a number that rates them on a scale between non-urgent to urgent to emergent.
After rating the patients level of urgency I will start my assessment. I always do a primary assessment and a focused assessment. If I am able or have the time, I put in a secondary assessment.
I then try to anticipate any orders the provider (MD, DO, PA, NP, etc.) may want. For example, someone with a fever will need a CBC, or someone with abdominal pain will need a urine sample. I start IV’s, gather labs, place the patient on the cardiac monitor, order some basic medications if indicated among other things. Once the provider has seen the patient, I carry out any further orders.
Once all tests have resulted, the provider will decide to either admit, monitor or discharge.
The provider will work with providers in different areas of the hospital to come up with the right placement for the patient. Every floor has specific parameters of vital signs they can work within, medications they are allowed to administer, types of diagnoses they can care for and level of “sick” they are trained and able to maintain on their floor. Some providers will accept the patient but need further treatment performed in the ER before they are safe to come to a specific floor. For example, if a patient has a high BP, they may need to be medicated and monitored until their BP is within the limits that are acceptable for that floor before they can go to the floor.
Once all parameters have been met and the bed is ready, report needs to be given to the accepting nurse and the patient needs to be transported to the floor. If the patient needs to be monitored, that is the job of the ER nurse. You will leave your assignment and transport that patient to their room on a monitor.
Sometimes a patient will need to stay in the ER to make sure they are stable for a period of time. A patient who had an ingestion, an allergic reaction, a medication or other situations, may need to stay in the ER but don’t really need to be admitted. These patients require vital signs every so often (depending on the situation) and intervention if anything goes awry.
For example, if you give a patient morphine before discharge and they don’t have someone else to give them a ride, they need to stay in the ER until they are safe to drive.
Most patients will be discharged after they have been evaluated and all life-threatening causes are either eliminated or taken care of. Stable patients that don’t need hospitalization will be discharged with instructions to follow up with either their PCP or a specialist. Patients need to have their vital signs taken within one hour of them leaving the ER and their discharge instructions need to be reviewed.
During the last hour of my shift, I go into beast mode. I make sure all my vital signs are up to date within an hour of when the new nurses shift will start, I update a plan of care note, I make sure all testing that I can control has been accomplished and I pack up my workstation.
I give report, put my coat on, clock out and leave the building. Deuces my friends!
Susan DuPont, BSN RN CEN is an emergency nurse at a Level 1 Trauma Center. She is a nurse blogger at bossrn.com where she inspires nurses to be the best version of themselves by promoting education and preparedness.
Kati here! I wanted to provide some additional helpful resources for the ER nurse.