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I used to wonder what happens inside the Emergency Room of hospitals, what it would be like for a patient, for a doctor, and most especially for a nurse. As a nursing student, and as part of our program I was given an opportunity to have a clinical experience inside the Emergency Room. I had a three hour experience inside the emergency room. Inside the emergency room, I took care of a patient who was admitted for food poisoning. My job was to take care of the patient and to assist the doctor.
But the focus of the experience was primarily to take care of the patient.
Our patient was there because of food poisoning. He was being administered with Flagyl (metronidazole) , an oral synthetic antiprotozoal and antibacterial agent. I helped in the medicine administration. I removed the Nasogastric tube, which was passed through the nose and down through the patient’s nasopharynx and esophagus into the stomach. The flexible tube made of rubber or plastic was used to remove the contents of the stomach, including air, to decompress the stomach, or to remove small solid objects and fluid, in this case the poison, from the stomach.
The process was quick but I had to be careful because I was mindful of not hurting the patient in any way, I know that the removal of the nasogastric tube would cause discomfort and pain on the patient if I was not careful. My participation in the treatment of the food poisoning patient was little but I would say indispensable.
What counts most was the care that I gave the patient. A nurse inside the emergency room must at all times be attentive, alert and prepared. Inside the emergency room, the pace is quick and one should not be negligent of details. Every patient admitted are in need of urgent attention, which must be given.
I was interested in the fast paced environment inside the emergency room. The movement of people gave me energy. The adrenaline level of people was high and was contagious, such that if you were there, you would feel the rush and would be driven by the same energy. However, my experience was only for three hours and I can only speak for myself. I believe that should one be employed as an emergency room nurse, one should know all the aspects of this type of nursing. A nurse may be come across several setbacks such as injuries from sharp objects such as needles, blades, etc.
Also, patients in the emergency room have not been diagnosed before coming, thus they may present a risk of infection . The stress of handling patients , some of whom may be heavy may bring about musculoskeletal problems and back pain . Continuous work while standing or walking causes fatigue and leg problems. These possibilities must not detract a nursing student. They are only possibilities, but with proper care and diligence they may be avoided. What is important to take into consideration is that in the emergency room, we help save lives by assisting those who need urgent care and medication.
The role of an emergency room nurse can be demanding and may require a nurse to use many different nursing skills at certain times to take care of a variety of patients. The main role is the nurse must be skilled in client assessment, priority setting, critical thinking, multitasking, and communication. The nurse must be knowledgeable and able to make some decisions independently. The nurse also needs to be able to prioritize so the pts who are at highest risk of major injury or complications are treated first. In a busy ER, time management is important too because there may be a lot of pts waiting for care. The nurse must be mentally prepared for rapid change and be able to keep calm in hectic situations. The ER nurse must be able work well in a team and be able to interact with all levels of ER professionals in order to give the pt the best possible care. ER nurses also need to be flexible and adapt quickly to rapidly changing situations. Nurses usually choose to work in the emergency area because they dislike routines and thrive in challenging, stimulating work environments.
In one situation I observed, a male came in with chest pain. The nurse went to get him from the waiting area right away and hooked him up with the heart monitor and got him ready for an EKG. The nurse stayed calm, and gathered the information from the pt next. She had her own system for what she normally does depending on the level of the pt’s injury. Another key role is teaching. The ER nurse needs to make sure the pt knows what to do after discharge and/or when they may need to return to the ER for further testing or treatment. There are some similarities and differences in the roles and responsibilities between emergency care nurses and other general staff nurses.
The scope of practice for ER nurses includes managing pts across the lifespan; from birth to death. Other general nurses usually pick their area of work, so they mainly work with pts who have certain conditions, mostly all adults, or mostly children. Usually prior to employment in the ER most nurses are required by employers to have 6 months to one year in an acute care medical surgical or critical care unit before working in the ED. This is so they have developed some of the skills and competencies in basic nursing care and organizational skills before entering the ED, while the general nurse can start out on a medical surgical floor with no previous experience (other than school and their license to practice). The ER nurse is also required to have two general types of certification: the Health Care Provider Basic Cardiac Life Support and Advanced Cardiac Life Support.
Some facilities even require Pediatric Advanced Life Support and the Certified Emergency Nurse certification. The general nurse does not need to have any special certifications. The ER nurse also has a higher risk for errors and adverse events because of the chaotic nature of emergency management and key health risks are not as evident. For example if a pt comes in unconscious, and the pt’s name, health history, and allergies aren’t known there is a higher potential for error. The general nurse usually has an updated H & P with allergies sent to the floor right along with the pt who is wearing a name band already. Similarly, the ER nurse and the general nurse all need to have competence in basic nursing skills, time management, prioritization, knowledge, and critical thinking.
They must both have knowledge to be able to work independently. Depending on the place of employment most facilities require all medical personnel to have an updated CPR card, so ER and general nurses have this in common also. Another similarity is communication. Both nurses still need to be able to communicate well with other medical personnel and pt’s families. In the emergency care area the nursing process is a little different, but parts are still used, although with the rapidly changing environment, the process is sometimes a little out of order. First, the ER nurse assesses the pt usually by asking questions about health history, allergies, and reason for coming to the ER. Next, the emergency nurse must still do a head to toe assessment, depending on the signs and symptoms exhibited by the pt. Another ER assessment done in trauma pts is the use of the “primary survey,” which organizes the approach to the pt so that immediate threats to life are rapidly identified and effectively managed. The primary survey is based on the mnemonic “ABC” and “DE” for major trauma.
This is the order of priority. The A=airway/cervical spine, B=breathing, C=circulation, D=disability, and E=exposure. Sometimes nursing diagnoses are noted if the pt is at high risk of injury. Next the doctor assesses the pt, so no nursing diagnosis are planned or implemented at this time. The doctor then makes the decision is the pt needs to be admitted to the hospital or if the pt will be discharged home with instructions for continued care or follow ups. If the pt is admitted, the nurses will start to put together nursing diagnosis which will be planned, implemented, and evaluated when the pt moves a room in the hospital.
In the ER pt care is coordinated by use of team work. One nurse will start to assess the pt. The receptionist will get a wristband printed up. The ER nurse will report to the ER doctor prior to the pt being seen by the doctor. The nurse also collaborates with x-ray and ultrasound technicians, respiratory therapists, lab technicians, and social workers. The interaction between all the medical personnel helps assure the pt receives the care and testing needed. Autonomy, or independence is a key trait the ER nurse must display. Due to the high volume of pts, various levels of injury, different disease processes, and complications a nurse needs to be well educated on what to do in these situations, so she can independently report to the physician or start up emergency facility protocol without a huge amount of help or questions for the physician.
In order to work independently the nurse must be skilled in pt assessment, priority setting, critical thinking, multitasking, flexibility, and adaptability. The nurse also needs to have a good knowledge base. The ER nurse also uses the triage system independently to prioritize care. The most commonly used triage system used under usual conditions is the three-level model: emergent, urgent, and nonurgent. Emergent triage means that a condition exists to a pt that poses an immediate threat to a pt’s life or limb. Urgent triage means that the pt should be treated quickly, but that an immediate threat to life does not exist at the moment. Nonurgent pts can generally tolerate waiting several hours for health care services without a significant risk of clinical deteriorization.
Some of the standards of care in the St. Nick’s ER involve quality improvement measures. Some measures implemented are care maps, discharge protocols, standing orders, and measurement tools designed to save lives and reduce healthcare costs by lowering recurrences. Also secondary prevention guidelines are also implemented. The ER has special emergency services protocol sheets that are referred to as pts come in to tell the nurse what would be done for each pt in specific situations, for example: burn pts, bleeding pts who are on coumadin, suspected meningitis, and asthma pts. As stated earlier, sometimes nursing diagnoses are noted if the pt is at high risk of injury. Otherwise, if a pt is being admitted to the hospital, nursing diagnoses are planned or implemented at this time. If the pt is admitted, the nurses will start to put together nursing diagnosis which will be planned, implemented, and evaluated when the pt moves a room in the hospital. An initial assessment including a full set of vitals is usually done upon arrival to the ER. Vitals including temp, pulse, blood pressure, resp, and O2 sat. After the initial assessment focus charting is done. This focuses on anything abnormal that was found and the reason why the pt has came in. Not all people who come in to the ER utilize it correctly. I observed a pt that has been coming in to the ER monthly for the past year for a toothache. I think this pt needs to see a dentist instead.
He stated he did not have insurance, but he did have medical assistance, in which there are a few dentists who accept this form of insurance. Another pt that came in to the ER ended up having a bruise from a fall 3 days prior. I think the pt just was looking for an excuse to get out of work. So, there are people who come in with problems that are either minor or could have waited so the pt could have been seen in the clinic the next day. According to our textbook, the most common reasons pts seek emergency care include chest pain, abdominal pain, headache, and fever. I did observe a few other pts who really did come to the ER for valid reasons. One lady was dehydrated from nausea and had severe orthostatic hypotension.
Another pt came in with seizure-like symptoms. One man came in with chest pain. A 16 yr old came in by ambulance with possible neck and or spinal injuries from a car accident. These examples are of people who utilized the ER with real emergent situations. The emergency nurse also impacts the health of the community. One way is when people call in to the ER for advice on whether a pt should be brought in or not the nurse reviews the pts signs and symptoms and gives educated advice. Another way is by teaching. The ER nurse does a lot of teaching to pts who come in to the ER, especially to those who are not admitted to the hospital. The pts are educated on what kinds of signs and symptoms to be aware of depending on their situation, when to come back to the ER, if the pt needs to follow up in the next few days with their physician, and on the medications that may be prescribed.
The ER nurse is also trained to treat people for environmental injuries like poisonous bites and heat stroke and mass casualties like earthquakes and fire, so the ER nurse gives the community a sense of security to know medical personnel are there in case of injury. To support appropriate use of the emergency room, health care providers can advertise what kind of injuries and problems people could have to come in to the ER for treatment or assessment. Health care providers can also refer pts who call in on the phone first to go to the clinic the next day if a minor problem. When appropriate ER pts come in health care providers can boost their confidence levels by stating, “It’s good that you came in to be checked out.” Another way is teaching. Some pts may not even realize they are coming in to the ER for minor problems.
Health care providers need to stress signs and symptoms that may be present for a pt to use the ER. The way the Wisconsin Good Samaritan Law is written is a little confusing due to the wording and the different interpretations of the meaning of the law. My understanding of the Good Samaritan Law is it states that any average citizen who gives emergent care at the scene of an accident will not be liable for his/her actions. But, if the person is trained in health care, like a nurse, he/she can not provide any services or cares beyond his/her training level or they could be liable for their actions. The law also does not state that any health care professional, including nurses have to stop to help at the scene of an accident (although it would be good of them to). Also, if health care professionals, including nurses, volunteer at school sponsored athletic events and render care to anyone before, during or immediately after the event, within the scope of their practice, they will not be liable as long as they are not being paid.
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