Emergency Department

(This section is written by Susan, our trusty ED nurse)

In the ED, you will get a plethora or patients to weed through. You cannot turn a patient down because you are full or because you don’t know how to care for that type of patient. In the ED, you take everyone. They will fill the waiting room, line your halls, and there are days that you didn’t know so many people lived in your town.

That's why the ED nurse needs to have knowledge that is vast enough to care for all types of patients, but focused enough to eliminate life-threatening situations. You have heard about your ABCs before, but in the ED it truly guides your practice. Airway and breathing is a quick assessment and is easier than circulation. If the patient is talking and their pulse ox is within normal limits - you move on to circulation.

Circulation (AKA cardiac issues) is more time consuming and requires a more detailed assessment of the patient. ED nurses are looking for signs and symptoms of a heart attack, getting a lot of ECGs, interpreting those ECGs, and eliminating any life-threatening cardiac conditions. To work in an emergency room as a nurse you must be ACLS certified. There isn’t a code team or a rapid response team that responds to unstable patients - you are the code/rapid response team.

What is a cardiac emergency in the ED

It is important to understand what a cardiac emergency is as an ED nurse. Besides the extremes of a very fast or very slow heart rate, and a very high or very low blood pressure, cardiac emergencies include: heart attack (STEMI, NON-STEMI, unstable angina), ventricular dysrhythmias (V-tach, V-fib), and hemorrhaging. That is it. Everything else may be urgent or concerning but not emergent life or death situations.

12-lead, 5-lead, and 3-lead ECGs in the ED

Being comfortable with your cardiac rhythms is necessary to be a safe nurse in the ED. You will have a rhythms test before you can staff the floor and, depending on the hospital, you may have one every year as a part of your yearly competencies. You will need to be proficient in 3-lead, 5-lead, and 12-lead ECGs. If you see something suspicious on the 3 or 5-lead monitors, you need to get a 12-lead ECG. You do not need a doctor to look at the patient or put in an order to get an ECG on a patient. This is different than on the floor. A nurse's ability to discern if a patient needs an ECG and to obtain an ECG is within the scope of an ED nurses practice.

Humility of the ED nurse

The single most important thing I learned as an ED nurse is to bury my pride and admit when I don’t know something. Bet you didn’t think that was a trait of an ED nurse since they mostly walk around with a ton of confidence, but it is vital.  If you are not good at reading ECGs, practice at home and ask for help while at work. You should not spend 10 minutes to interpret an ECG, have another nurse lay eyes on the ECG if you are in doubt. All ECGs will be eventually interpreted by the attending physician but you are not going to want to interrupt the physician to read your normal sinus ECG.

If the patient is having, let say a STEMI, you will stop the physician and have them look at the emergent ECG you have. It could go the other way too, let's say the patient is having a STEMI and you wait 30 minutes until they are finished doing a non-urgent exam - that is a problem. That is why it is important to know how to interpret ECGs.

Everything in the ED is fast-paced and a huge saying is “time is tissue”. This applies to the cardiac, neurology, respiratory, and basically every system, so reading an ECG is only part of your job as an ED nurse. Because in the ED you may be seeing multiple patients at this fast pace, it is important to know your drug interactions. Stopping to look up every drug interaction delays patient care on potentially serious conditions.

Example

Let's say you are taking care of a patient who had a seizure because their Dilantin levels were too low. So they are getting IV Dilantin to increase their levels when all of a sudden they go into cardiac arrest. The first drug you give for cardiac arrest is Epinephrine. Epinephrine and Dilantin are NOT compatible in the same IV line. You would need to know this quickly, stop the Dilantin if that is your only IV line and flush it with 20mL of normal saline before giving the Epinephrine safely. You will not know every medication interaction but for the emergent drugs, especially your ACLS drugs, you need to know what they are compatible with and are not compatible with as well as how to administer them.

Triaging for cardiac conditions in the ED

When a patient comes into the ED, you will initially only know what they look like. You won't have a chart to read before the patient checks in, you won’t have vital signs, lab work, CT results, etc. What you have is a patient to look at and determine if they are sick or not.

Key things to look for to identify a cardiac issue include diaphoresis, paleness, cyanosis, grabbing at the chest, inability to articulate or speak, and syncope. This doesn’t mean that someone who looks fine isn’t having a heart attack, it just helps you triage patients to see first, basing that judgement on the most likely patient having a life-threatening situation on first glance.

After the first glance, the first thing you do in the ED, no matter the situation, condition, or emergency, is get a set of vital signs. If the patient is talking (meaning: airway/breathing is good), you listen to their reason for coming into the ED while determining if they need an ECG. It’s almost like silently challenging them to convince you to NOT do an ECG.

Epigastric pain? ECG.

Tooth pain the radiates down their jaw? ECG.

Racing heart feeling? ECG.

Finger laceration? No ECG.

Finger laceration after a syncopal episode and grabbing for the table but gripping a knife instead? ECG.

Patients that have an extremely low or high heart rate, or extreme hypotension or hypertension, need to be seen immediately. The vital signs will help assess the circulation. When a patient has a low blood pressure, do not freak out until their Mean Arterial Pressure (MAP) is under 60 AND you have taken it manually.

Medical screening for cardiac conditions in the ED

Another important consideration for the emergency department is to ask the patient about their medications and history. You will not always have an updated list for the patient. Making sure they have this information put in the medical record is super important if time and the situation allows. You may be relying on family members, friends, and EMS to help put together a picture for the patient.

Sometimes you will have to ask questions like, “Have you ever had an irregular heartbeat?” rather than, “Do you have any cardiac history?”

A patient will not always think about hypertension as a cardiac issue either so make sure to specifically ask about their blood pressure. Patients come with all levels of health literacy, and many are not aware that some of the medications they are taking are cardiac medications.

The same can be said about DVTs, PEs or Strokes. Ask specifically about a personal or family history of blood clots. Watch your medical jargon because this can lead to a patient not giving you pertinent or vital information solely because they don’t understand.

Intensive Care

Patients in the ICU world come from a plethora of places. They may have presented from the ED, they may have coded or decompensated out on the floor or stepdown, just came out of the OR, a direct-admit from another hospital, or maybe they were air-lifted in from the scene.

Your cardiac assessment in the ICU is not as intense as the neuro assessment, but just as crucial. To compare cardiac and neuro: neuro is more subjective and based off of serial neuro exams. Cardiac is more about the numbers and devices. Both are equally challenging, but in different ways

You are also most likely working with even more advanced equipment like Swans, IABPs, impellas, and more. So, not only are you going to be responsible for listening to heart and lung sounds, but also making sure equipment is functioning safely and properly, while analyzing different numbers like Sv02, cardiac output, and more.

Your assessment should be like a golf swing - do it the same every time. [We are not talking about an actively unstable patient right now.]

Here's an example of a cardiac golf swing:

1. Print and interpret telemetry strip
2. Look at latest labs
3. Check bedside monitor to ensure correct vital sign parameters are entered
4. Listen to heart and lung sounds
5. Check peripheral pulses
6. Check incisions (as indicated)
7. Check all invasive lines; level and zero
8. Check all equipment (for example: cooling device, foley to ensure patency)
9. Check all running IVs for correct drug and infusion rate
10. Check vital signs; intervene for those out of parameter

Abbreviated golf swing:

1. Tele
2. Labs
3. Monitor
4. Sounds
5. Pulses
6. Incisions
7. Lines
8. Equipment
9. IVs
10. Vitals

This is just an example, but if you prefer a different flow or have something else you need to incorporate, add it. When you're first starting out, you could tape your golf swing to your clip board, or make it part of your report sheet until it becomes second nature.

One of the biggest differences between the ICU world and the others is all the equipment you're responsible for. We have an entire section dedicated to this later on. But make sure you've got a routine of checking those devices built into your assessment mindset.

Nursing Floor

The nursing floor is quite different than the other two units, with different assessment considerations. Rather than assessing every 4 hours or more often, floor nurses typically only need to complete a full head-to-toe once per shift or with major changes.

Because the floor nurse isn't doing an in-depth look over the patient multiple times a shift, it's important to be able to clue into concerning things as you're caring for the patient. This is more long-term monitoring than acute intervention than the other two, so having your eyes and ears alert for subtle changes in assessment is key.

Examples

• While you assess them this morning and their lungs were clear, do they all of a sudden sound like they have a congested cough? Maybe another listen to their lungs would be a good idea, plus checking their I&O, and oxygen saturation.
• Earlier their incision looked fine, now it's starting to look red and is oozing a bit. Maybe you need to check their other incisions, look closer at the concerning one, take a temperature, see what antibiotics they're on, look at their white count, and call the provider.
• Their heart rate was 70-90 in atrial fibrillation a few hours ago. Now it's creeping up to the range of 100-110. Was their beta blocker held for some reason? Are they dehydrated a bit? What's their I&O? What was their latest pressure? Let's address this before it turns into a heart rate of 130 and is finally triggering the alarm.
• They were complaining of mild abdominal pain earlier and had only had a small bowel movement a few days ago. You encouraged them to ambulate, but now they are in even more pain. Maybe you should listen closely to bowel sounds and inquire more specifically about the amount of the last bowel movement and see if stool softeners have consistently been held. Maybe they need an x-ray (KUB) because they're developing an ileus.

Note these examples aren't drop everything and OMG call the physician now scenarios, they're smaller and more subtle assessment changes requiring prompt investigation. And if they don't, then the patient is having early signs of a change that aren't going to be detected until later when it's progress from a problem to an urgent issue.

So, as you're assessing and monitoring your patient, keep your eyes out for these assessment changes. These small and subtle indicators are much more common things you'll deal with than the major, overt, concerning findings like v-tach, afib with RVR, respiratory distress, and so forth. We try to get really prepared for these big scary changes, but what we really need to spend just as much time and mental energy preparing for all the subtle ones as well.