Violence in the Emergency Department

“You don’t have a backbone.”

“You need thicker skin.”

“You need to suck it up.”

“It happens.”

“They didn’t actually hit you so it’s pointless to press charges.”

“She’s a really good nurse, I think you’re just over-reacting.”

These are some of the phrases that have been said to me over the past month or so. The emergency room is a fast-paced, intense environment that requires you to be quick on your feet, control your emotions, and be 10 steps ahead at all times.

A lot is “tolerated” in the ER. You have frequent fliers who waste resources by hitting the call light every five minutes asking for food, a blanket, to change the channel, etc. You have a population of people who use the emergency room as a primary care office, also wasting resources and complaining that they aren’t being seen fast enough. You have people who come in for drug overdoses, alcohol intoxication, and “incarceritis”.

I don’t know the exact number, but there is a small percentage of emergency room patients who actually need to be there – those that need admission to the hospital, need resuscitation, need a bone put back into place, etc. In theory, a majority of resources should be poured into this category.

Regardless of why someone is coming to the ER, we do our best to help them. We prioritize based on ABC’s and Maslow’s hierarchy of needs. If someone is having trouble breathing, the turkey sandwich that another patient is requesting has to wait. It is not a first come first serve environment.

ENA believes emergency nurses have the right to education and training related to the recognition, management, and mitigation of workplace violence. The mitigation of workplace violence requires a “zero tolerance” environment instituted and supported by hospital leadership.

Emergency nurses association

Violence should be a zero tolerance occurrence, according to ENA. It is a felony in 31 states to assault an emergency department healthcare worker. So why are there so many unreported incidents? I myself have been kicked in the head, verbally abused, lunged at, and had furniture thrown towards me all in the past nine months. I officially reported one of those incidents to the hospital, but I didn’t file any charges or report the other ones. Why is this? Why is there a culture of tolerance where I work?

After the most recent incident, where a patient began verbally abusing me and another staff member, then proceeded to start throwing things, threatening to punch me, and lunged at me, I finally had enough. I wasn’t physically harmed in this instance, but it could have gone very differently.

I’ve been thinking about that incident every day since it happened. What could I have done to prevent this escalation? Looking back, some people just get angry, put up wall, and don’t let anybody in. I did my best to use my therapeutic communication, but that didn’t work for her. She got angrier.

At the first sign of verbal abuse toward me, I immediately put up a boundary. “I understand that you are frustrated, but I will not be spoken to that way.” This did not go over well. It was time for discharge anyway. I left the room to get the papers. I handed them her and she threw them back in my face. “I don’t need your advice, you b*tch. I’m going to start punching people, starting with you!” At this point, I’m done. Security is called and she continues to escalate as she is escorted out of the building.

Although I’m leaving a lot of details out, this type of escalation occurs all too often.

It needs to stop.

Let me bring in another type of violence – lateral violence. Also known as bullying or harassment in the workplace. We all have those toxic co-workers, and if you don’t, consider yourself lucky. You know, the ones who are passive aggressive, who spread gossip, and who are condescending. Unfortunately I have fallen into the trap of being bullied by a colleague. So much so that one night I cried my eyes out in my car. The shift itself wasn’t terrible – my patients were fine. It was the way I was treated.

The culture in the ER is often lead by the phrases that began this post. “You need thicker skin.” But why? Why should I tolerate this type of behavior? Why are nurses treating other nurses this way? Why am I being punished for being a new nurse? I do not have to sit there and take it. I have every right to confidently stand up for myself.

I do have a fear of standing up for myself. I don’t know if it’s the society we’re living in or the way I was raised, but if I stand up for myself, I’m either labeled as “sensitive” or a “b*tch.” There is no inbetween in my head. Maybe a few therapy sessions could do some good with that battle in my head.

Words hurt. Words have always hurt me. I can take physical pain, no problem. But the words of a bully will fester in my mind for weeks. Now I find myself being nervous around these particular colleagues. I feel as though asking for help shows weakness. I don’t feel like myself. It’s causing anxiety so much so that I request to switch assignments if I am too close to this person.

I said something to a supervisor and I made things worse for myself. I feel as though I’m not believed because this person is experienced. Of course I don’t talk about it with other people because I’m not the type to spread gossip or get everyone in my business.

If you have any advice, let me know, because I’m at a loss here.

There are hundreds of resources, studies, and articles out there about both types of violence. If you “google” it, thousands of entries appear. Yet it is still happening.

The Journal of Emergency Nursing posted an article about lateral violence in 2012, you can find it here. Another great resource is https://stopedviolence.org/.

Help me create a culture of celebrating each other, lifting each other up, and encouraging your peers to report workplace incidents. Under no circumstance should you allow someone else to violate your personal space or mind without your permission.

A Day in the Life of an ER Nurse

I know, it’s been a long time. It’s June. I last wrote over three months ago, and as we all know, life as we know it has changed. As a reminder, I am a new grad nurse in an busy inner city emergency room. This year has been one of the most challenging yet gratifying years of my life. This is a day in the life in my shoes.

At 1000 I wake up sore from the past two shifts. I take ten or so minutes to wiggle around, discovering two new aches and pains that weren’t there when I woke up yesterday: my jaw is sore from wearing a heavy NIOSH respiratory for at least ten hours of the day, and my right foot and ankle are sore for some unknown reason. It’s okay. It’s day three of three and I can get through it. I am looking forward to those sweet four days of freedom.

I hobble over to the Keurig. Coffee is a priority. I do my business in the bathroom as the bubbling sound of the Keurig breaks the silence in my apartment. My sweet black lab mix stretches herself out on the floor and slops up some water.

The mid-morning light streaming through my window reveals a nice blue bruise and swelling in my foot. Awesome. That explains the pain. I grab some ibuprofen and an ace wrap. I don’t have time to ice this morning. I’ll just have to deal.

I slowly pack up my bag and “lunch,” wondering if I’ll actually be able to eat it tonight. Not that my hospital doesn’t provide breaks, but often there just isn’t time to stop. I slap on some moisturizer and mascara. The only feature my patients and coworkers can see are my eyes. Makeup is discouraged because of the mask decontamination process. No concealer for the purple bags under my eyes.

As I walk down the hall toward the parking garage, I notice that my ankle really does feel unstable. I also have a backache, but that isn’t new. The light of the sun and the warm air hits my face. I take a big deep breath. I won’t see the outdoors for about twelve hours.

My car is a biohazard disaster. I haven’t had time to wipe anything down. Daily assignment sheets, syringes, flushes, angiocaths, and empty water bottles all make a rustling sound as I set my bags down on the passenger seat. I hate having a messy car. But I don’t have time today. Maybe on my days off.

My drive is easy. I listen to some of my favorite songs to raise my spirits. I have a long day, but I also feel excited to go to work. I love my job! I learn something new every day. I’m finally feeling more comfortable in my brand new career as a registered nurse. Most patients are appreciative of the work we are doing. I’ve been getting more “thank you for everything you do’s,” lately. I appreciate this part of humanity. I don’t come to work to be praised, but it helps.

I walk in an entrance which is normally public, but is now badge-in only because of the pandemic. I clock in, then wait for my assignment. Our census has been starting to go up. The regulars are starting to trickle back in. Today is the first day in a couple of weeks that the department is full. We have many admit holds, and most of those are ICU. My assignment is called “death row,” a row of four rooms at the front that typically have the worst of the worst (not including traumas). Any room in our department can receive any type of patient, however.

My intuitive nature has the ability to “feel” a room and know what moods people are in, particularly stress levels. I have really been working on not being an emotional sponge, something I have struggled with my whole life. I have my moments, but I’ve gained a better handle on compartmentalizing at work. As I walk into my pod, I can feel something in the air. Tonight is going to be really…interesting.

I, like most nurses, do “drive bys” of my rooms. I like to peak at each patient very quickly even before getting report. I can see a lot just from a glance, and that way I have an idea of which patient will be my priority. This time, I see two patients who are intubated with soft blood pressures. My other two patients are at least breathing on their own.

After getting report, I get completely gowned up with my mask, respirator, face shield, gown, and double gloves to go into my priority patient’s room. His pressure is tanking. I do a quick assessment. The ventilator is in place and on the correct settings given to me by the respiratory therapist. The patient’s oxygen saturation is only 85% at 100% FiO2. We are forced to be satisfied with that number. His MAP is about 62 and dropping. I need to figure out what the next step is. As I trace all of my lines, I discover that the vaso drip is occluded. I breathe a sigh of relief. I flush the line and restart the vaso. Two minutes later, I have a MAP of 72 and I throw two big thumbs up to the nurses and doctors watching me from outside the room.

One problem down, many to go. While in the room, I get a call from RT that the ETT needs to be moved back. I chart my assessment as I wait for RT to gown up to come into the room. I signal for my preceptor to come to the window. I want to increase sedation to move the tube now that the pressure is holding steady. Everything except the vaso is on extension tubing with a pump outside the room. I have to ask another RN to titrate the norepi, fentanyl, or versed. He’s kind of a bigger fella, and there was already some response to pain during my GCS assessment. There are no restraints, and if this guy pulls out his tube, he would most likely die.

I’m actually nervous to suggest titrating the Versed up. I’m a new grad. This is actually the first time I’m in a level 1 critical room on my own. There is a lot going on. This guy is super. freaking. sick. I know I have many hands outside the room to help, but my preceptor is giving me space to take the lead. I’m met with a “that’s a great idea, what do you want it at?” My preceptor pushes the buttons for me and shows me the pump screen to verify. Thumbs up, again.

RT is in the room. We come up with a plan of action for moving the tube. It’s just the two of us. There is a high suspicion that this guy is COVID+, so I don’t want to put other people in jeopardy unnecessarily. Our plan is in place. She nods her head. Moving the ETT is considered an aerosolizing procedure. She moves the tube and the patient starts coughing and moving his arms toward his mouth. Shit. I grab his arms and nearly lay by body across his to prevent him from moving. The ventilator begins beeping loudly, and the patient’s O2 sat drops to 70%.

“No, no, no!” RT exclaims. I do not like this situation. I motion to another nurse standing outside the room. I point up and she understands to increase the fentanyl. The versed is nearly maxed out and this guy cannot afford to lose any more perfusion. We get the ETT secured to the new location, and the patient calms down. This whole time, we are trying to talk to the patient to reassure him. I don’t know what he can hear. I don’t know if we’re helping.

Thirty minutes is way too long for an initial assessment when I have three other patients to see. I need to get out of this room, not only to limit my exposure, but to also see my other, more stable, intubated patient. I wait until his saturation reaches 80%, and I signal that we’re ready to come out.

Forty-five minutes into my shift, and I’m already soaked in sweat. I doff all of my equipment and take about 30 seconds to breathe before I have to gown up again to go into another room. This other intubated patient is hemodynamically stable, so I do a quick assessment and let the patient know who I am and what I am here for.

The next couple of hours I work with several people to get my sick patient to the ICU. Those warriors work very hard, so it takes a while to coordinate the transfer. We have to take at least four people in full PPE to transport this patient across the hospital, with other folks ensuring the hallways are clear so that other staff doesn’t get unnecessarily exposed. Before we even leave the department, we are all drenched in sweat.

WooCommerce

After about 30 minutes, I am back in the department and of course there are a dozen more tasks that have piled up since I’ve been gone. There’s no time to breathe, take a drink of water, or pee. I have to make a priority list and get several things done first.

I’m still learning how to manage my time. Every few hours, I try and make a “list” of my priorities, whether that be in my head or chicken scratch on paper. I also try my best to help my co-workers as they deal with codes, strokes, STEMI’s, and frequent fliers.

The biggest time hurdle of the day is a septic DKA patient that I can’t get lines on. They need at least two IV’s, two sets of blood cultures, an insulin drip, two different antibiotics, and fluids. My 22g in the thumb isn’t going to cut it. It takes time to find someone to sono, and finally I come to the conclusion that this patient needs an EJ. An hour later, I’ve missed my sepsis times and I’ve fallen behind on my other three patients.

Seven hours into my shift, I haven’t stopped to pee, snack, or thoroughly chart. I’m okay, though, but it peeves me when my 2 hour LOS is complaining that we are starving her to death by not offering a turkey sandwich. What the public doesn’t understand is that in an emergency room, we treat emergencies. If hunger is your biggest problem then I have good news for you. You are going to survive. I do care, but I am trying to keep the person next to you alive.

It’s finally time for my “break.” This consists of rushing to the microwave, setting it to 2 minutes, and hoping I get to come back to eat it. I also gulp down a huge glass of water and some tylenol so I can convince my stomach that it’s full for just a little bit longer. Luckily, today, I get about 10 minutes to eat and chart at the same time. One of my patients is up for discharge, so I used this time to back-chart. This patient was a soft ESI 3, and probably could have handled things at a primary care. But unfortunately, many primary care offices are not seeing patients, so people have no choice. I write some quick assessment notes on this 34 y/o knee pain. His vitals were stable the entire time and his biggest concern was getting a work note.

My food is somehow already gone, and I mask back up. I place the N95 on, secure my surgical mask over it, and I wipe down my eye protection before putting it back on. I scrub my hands and continue back to work. The next four hours whiz by, as I shuttle about ten patients in and out of my rooms. Some are easy in and out discharges, but others are ICU holds. I fall extremely behind by 2300. I have been asking for help when I can, but everyone else is slammed, too. By midnight, I still have work to do. I don’t like leaving tasks for the next shift, especially when they are simple. But I just got 3 new patients between 2315-2330. I have been focusing on the septic one and haven’t even worked up the others. I did a drive by, and I know they are hemodynamically stable and breathing, so I don’t have a choice here.

The nurse taking over for me kindly waits for report. I give some details while pulling heparin out of the med room. “This is for my septic guy with multiple PE’s. You’re gonna want to see him first. His pressure is soft, he’s alert and oriented to himself only, and he was a hot mess of a transfer from another hospital. The good news is that he has 3 lines…” I chuckle a little on that last part.

“You have one COVID+ in room 16. He’s stable on 4LNC, 93%. Nice guy, low maintenance, everything’s done on him. I haven’t seen 17 yet but she is ambulatory, breathing, and I think someone did line and labs. She is here for a rash. Room 19 is a 35 y/o abdominal pain from a chronic issue. Line and labs done. She is very uncomfortable and the doc ordered morphine. But she is stable.”

Any floor nurse or ICU nurse would cringe at the report I just gave. Just a few sentences for 4 patients. That’s all we have time for. Just the basics. ABC’s. So if you’re an ICU/floor nurse reading this, understand why we give the report we give! Sometimes we just don’t know. In the ER, if I see someone walking themselves into a room, I know that I probably have a few extra minutes for my sick patient next door. My goal is to get vital signs within 5 minutes of all new patients, ambulatory or not. But sometimes, all I have time for is, “Hi, I’m Sky, I’ll be your nurse today. I’m going to hook you up to the vital signs machine, can you tell me briefly what brought you in today?” I get them hooked up, make sure their ABC’s are intact, and then I’m out the door.

It’s not that we don’t care, it’s just that we literally have people dying.

I meet up with the other girls on my shift. We all walk out together and each person vents about the shift. We all just got our asses kicked. But I’m happy. I’m exhausted, but I love my job and I wouldn’t trade it for anything!

Skyanne, BSN, RN

P.S. ALL of these patient scenarios may be based on real-life cases, but none of them actually match patients I had. It is merely a mix of the typical cases that I see in a day. There are NO pieces of identifiable information in this post, and even if there were, I made the numbers up. Room numbers, too.

This post may contain affiliate links. This means that, at no cost to you, I may make a commission if you click through and make a purchase. Contact me with any questions!


Check out some of my other posts!

Violence in the Emergency Department

“You don’t have a backbone.” “You need thicker skin.” “You need to suck it up.” “It happens.” “They didn’t actually hit you so it’s pointless to press charges.” “She’s a really good nurse, I think you’re just over-reacting.” These are some of the phrases that have been said to me over the past month or […]

Read More

A Day in the Life of an ER Nurse

I know, it’s been a long time. It’s June. I last wrote over three months ago, and as we all know, life as we know it has changed. As a reminder, I am a new grad nurse in an busy inner city emergency room. This year has been one of the most challenging yet gratifying […]

Read More

Reality Check: Being a New Grad in the ED

Hellloooooo! It’s been a hot minute. Since I last wrote, I graduated from nursing school, started my residency, and passed my NCLEX! Woohoo! I wish I could say that the NCLEX was the last stop on the nursing struggle bus, but really starting to feel like it’s stop number 5 out of 100. I accepted […]

Read More

Reality Check: Being a New Grad in the ED

Hellloooooo! It’s been a hot minute. Since I last wrote, I graduated from nursing school, started my residency, and passed my NCLEX! Woohoo! I wish I could say that the NCLEX was the last stop on the nursing struggle bus, but really starting to feel like it’s stop number 5 out of 100.

I accepted my dream job. I had a picture of how it was going to be. I spent over 300 hours in the ED during nursing school, so I thought that I would have *somewhat* of a smoother transition into practice. I WAS SO WRONG. Being a new grad in the ED has proven very difficult for me.


Canboc Stethoscope Carrying Case for 3M Littmann Classic III/Cardiology IV Stethoscope – Extra Storage Taylor Percussion Reflex Hammer, Reusable Medical LED Penlight

One, the ED I’m working in now is a little bit over twice the size that I had experience in, plus, it’s a Level 1 Trauma Center. New grads don’t really touch the trauma bay, and I didn’t expect to for a couple of years anyway. However, my coworkers are super great and are very supportive of learning opportunities! So I have spectated in the trauma bay a few times for some interesting cases.

Secondly, I don’t know where the heck anything is. I’m still getting lost, it takes me twice as long to find supplies, and ALL OF THE EQUIPMENT IS DIFFERENT — The pumps are a different brand and can only handle one primary line and a piggy back – no adding channels…gotta get another pump…????, the tubing is different (as well as the way to prime), the IV angiocaths are different (I do need way more practice with sticks, though), the blood culture bottles are a different shape and color, the medication dispensing system is different, the labeling process for specimens is way more complicated (the hospital recently transitioned to EPIC, so I’m not sure they’ve caught up with what other hospitals are doing), labs are drawn from different colored tubes and therefore the order of draw is different, mixing antibiotics is more complicated, requires an extra step, AND an extra piece of equipment that I’m not used to either. I could go on…but all of these little things are slowing me down immensely.

Thirdly, I am getting different instructions and directions from each nurse I interact with, so if I do something that isn’t quite what that person does, I am also slowed down because they want to explain what they are doing and why. Most of the time, I learn something new and am very excited to have a more efficient way of doing a task! But sometimes I just want to tell them that my preceptor instructed me a certain way and I would like to keep that habit. For example, I am already familiar with EPIC, but this hospital just transitioned. There are a dozen different ways to find information in the EHR. I have my favorites saved and my hands literally have two years of muscle memory to find certain pieces of information very quickly. I’m having trouble finding the balance here. I love and appreciate each piece of advice, but in the end I am responsible for my license and charting, and as long as it accurately reflects the patient’s condition and care within facility policy and the board, it’s six of one and half a dozen of the other. If you’re reading this and have advice–let me know!!

Let me get to the fun parts!!

Yes, the transition has been tough, the patient load is insane, and I feel like I got hit by a train. But I have learned SO MUCH in the three weeks I’ve been in patient care. I’ve seen a lot of new cases such as Cushing’s triad, clamshell emergency thoracotomy, ROSC, subarachnoid bleeds, and open fractures. I’ve also been able to reenforce and improve my knowledge and skills when it comes to the common cases I saw in my internship such as RSI’s, STEMI’s, strokes, and sepsis.

Being a registered nurse is really, really fun. I love seeing immediate improvement in a patient from an intervention or medication that I gave. Everyone is so supportive, and although I am a new grad, I feel like a part of the healthcare team. No one has treated me poorly or looked down on me (at least not to my face or that I know of). I’m really struggling with time management and clustering care, but my preceptors are supportive and patient.

The skill that I feel most confident in right now is my “customer service” skills. I can talk to anyone. I can stay calm in front of patients and do my best to explain what is going on. I can grab that extra blanket or take 15 seconds to take deep breaths with my patient. But I can’t wait to get better at it!

The only advice I feel qualified to give right now as a 3-week-in new grad in the ED is:

  • Don’t be afraid to ask questions! I feel like I ask a question every 5 minutes…
  • Be confident in what you know, but have the attitude that you can always, always improve and learn something new.
  • You can advocate for your patient right away! If something doesn’t seem right, grab someone for a second look.
  • You are going to feel like you are drowning, but my supervisors and preceptors have been telling me that it is a normal feeling.
  • Write things down (checklists, SBAR, questions, etc.).
  • Write out goals for each shift and take 2 minutes to share those goals with your preceptor.
  • Be appreciative of every learning opportunity and be respectful!
  • Learn some positive phrases such as, “Could you clarify this for me?” or “Could you remind me how to _____?” instead of “I don’t know.”
  • If you need to cry, do it in the bathroom or in your car!
  • Get to know your techs because they know more than you and can help you. I can’t tell you how many times a tech has saved my butt already.
  • ASK QUESTIONS. I already said that, but I feel that it is the most important for me right now.

I wrote this post about the transition before I graduated nursing school. It talks about some of the barriers new grads have with adapting to their new role. I re-read it today from a new perspective and thought it was really interesting. I am most definitely in that “first 3-4 months” where the grad nurse feels anxiety and self-doubt in the new role of a registered nurse.

I also grabbed this pocket guide called Emergency & Critical Care Pocket Guide. It’s a cute little flipbook that fits in any of my scrub pockets. It has basic information about common emergencies, ACLS charts, medication compatibilities, and more! I love being able to just grab it and learn something new.

Check out my previous post about essential emergency room supplies. Not much has changed about what I brought during nursing school versus what I bring to work now!

I also highly, highly recommend Hoka One One shoes. Listen, y’all. I had constant foot and back pain during and after my clinicals in nursing school. These shoes were recommended to me while I was in school, but I couldn’t afford them. After I got my first big girl paycheck, I ordered these shoes, and I feel like I am walking on a cloud. My pain has decreased and I can last much longer without feeling pins and needles.

Save up some money, buy some good nursing shoes and compression socks, and save your back and feet. You’ll thank me later!

Long story short, ER nursing has been a wild ride so far. I could go on and on. The bottom line is, if you are going straight from nursing school to the ED, get ready! It’s a lot. I’m only three weeks in, so please take anything I say here with a grain of salt. Not everyone will have the same experiences and I am not trying to portray that I am an expert.

Happy nursing!

Skyanne, BSN, RN


This page may contain affiliate links. This means that, at no cost to you, I may make a commission if you click through and make a purchase. Contact me with any questions!

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The Transition – Nursing Student to New Grad

As I countdown the days until graduation, and even more so count down the days until I take the state boards, the mix of nervousness and excitement running through my veins is increasing at an exponential rate. I am beyond thrilled that I accepted my dream residency position at a level one trauma center. I’m having nightmares about the NCLEX and I lay awake at night fantasizing about what my life is going to be like in six months.

I know it’s been a while since I’ve posted, but I wanted to talk about something that I feel is extremely important, but neglected in the nursing programs. I want to talk about the transition. I came across an article in the Nurse Education in Practice journal from 2016 written by Jennifer Ortiz. It talks about professional confidence during the first year after graduation and the common setbacks that graduate nurses experience.

Transition Theory

There is a theoretical framework for the phenomenon that new grad nurses experience. To keep it short and sweet –

Doing: First 3-4 months – The grad nurse feels anxiety and self-doubt in the new role of a registered nurse.

Being: Next 4-5 months – Competency is increasing, but self-doubt and anxiety continue as the transition between dependence to independence solidifies.

Knowing: Final 8-12 months – The new grad has established him or herself as a professional and feels like a contributing member of the field.

I don’t know about you, but knowing that these stages have been studied and written about makes me feel better that soon I will be sharing these feelings with my colleagues.

Communication

Ortiz found that a huge lack in nursing programs is communication with other healthcare providers. In my school clinicals, I seldom interact with doctors, and I was never given the opportunity to give report or SBAR for a change in condition or critical lab result. The only experience I have with this is through the nursing internship that I applied for. Only a handful of students from my school participated in an internship; it was not a regular part of the baccalaureate program.

I have about 70 hours of clinical left for nursing school (out of almost 900), and each time I have offered or asked to pick up the phone and page the mid-level, pharmacist, or respiratory therapist, I was rejected with, “no, I need to do it,” by my preceptor. Many of those times, I was fully prepared and confident to deliver a concise SBAR. I am not bashing clinical preceptors. They need to protect their license and I fully understand that, but as Ortiz mentions in the study, “new graduates nurses recounted many difficult experiences which involved communicating with other members of the healthcare team,” even after six months.

If you are a nursing student reading this, I encourage you to elicit the help of your instructors to be more involved in multi-disciplinary communication. I regret not speaking up for myself more often. Although we practice communication in lab and with each other, I am not 100% confident in this skill.



Mistakes and Errors

Another challenge reported in the Ortiz study that has “a negative effect on professional confidence” is the occurence of mistakes. I already feel guilty for making small mistakes, like leaving too many air bubbles after priming IV tubing, or grabbing the wrong size Foley kit for my patient as a student, so I can’t imagine having a license and making larger errors. Throughout nursing school, they nearly tattoo the rights of medication administration on our foreheads, yet we always hear stories about lethal medication errors.

The fear is real. Will I ever make a mistake that results in a sentinel event? If I am being completely transparent, I’m a major people-pleaser. Years of retail experience toughened me up, but some days I feel like a failure if one little thing goes wrong. I’d like to think that I would never make a huge mistake, but it would definitely dampen my professional confidence.

One time in clinical, I put a dirty pillow in the wrong place, and my preceptor reprimanded me in front of a patient. I felt humiliated! I wanted to go home after that, and the relationship between that preceptor and I was effectively ruined.

I hope that I have a preceptor who stays on the positive side and encourages learning instead of punishment. I hope that my preceptor encourages autonomy early in the game. If you are a new grad or a preceptor of a new grad, I would love to hear your feedback on communication and errors!


Ortiz, J. (2016). New graduate nurses experiences about lack of professional confidence. Nurse Education in Practice19, 19–24. doi: 10.1016/j.nepr.2016.04.001

This post may contain affiliate links. This means that, at no cost to you, I may make a commission if you click through and make a purchase. Contact me with any questions!

Shock: NCLEX Review

Shock – What is it?

Shock is a generalized systemic response to inadequate tissue perfusion. The major types are hypovolemic (absolute and relative), cardiogenic, distributive (neurogenic, anaphylactic, and septic), and obstructive shock. While they all generally have the same end result if not treated, the signs, symptoms, and interventions can be different for each type.

Shock is a complex process that can be explained down the the cellular level. We could get into cytokines and neutrophil entrapment, but this post is going to focus on nursing interventions rather than detailed pathophysiology.

As usual, I will be using my favorite textbooks/resources to write this post! Clicking on the links below will take you to an affiliate website where you can purchase them for yourself or browse around for other books.

Phases of Shock

Initial: Decreased cardiac output, decreased perfusion, anaerobic metabolism, lactic acidosis. You want to catch any signs and symptoms before it progresses any further.

Compensatory: The body is responding to the problem by increasing cardiac output and increasing oxygen delivery to tissues. (Sympathetic nervous system is in action here!)

Progressive: Compensation is not working and cells are starting to die off because anaerobic metabolism is not enough. (Systemic Inflammatory Response System)

Refractory: Shock is unresponsive to treatment and death is the probable outcome. (Multiple Organ Dysfunction Syndrome)

Hypovolemic Shock

This is the most common type of shock. It is caused by either a loss of volume (hemorrhage) or a displacement of volume (burn patients).

Signs/Symptoms/Assessment

  • Weak and rapid pulse
  • Hypotension
  • Restlessness/Altered mental status
  • Tachypnea
  • Cool, clammy skin
  • Oliguria
  • Sluggish capillary refill
  • Absent bowel sounds
  • Poor peripheral pulses

Interventions

  • Treat the cause!
  • If hemorrhage, hold pressure, replace fluids/blood
  • Insert 2 large bore IVs
  • Notify the HCP/rapid response team
  • Administer oxygen (high flow if necessary)
  • Maintain patent airway
  • Monitor vital signs
  • Monitor I/O
  • Assess skin color, temperature, turgor, moisture
  • Assess lung sounds
  • Elevate the legs (contraindicated if patient has spinal anesthesia)

Cardiogenic Shock

This is defined by a failure of the heart to pump adequately, which reduces cardiac output. This means that tissues are not being adequately oxygenated just as in hypovolemic shock. Some causes are myocardial infarction, valvular problems, and ventricular failure (reduced ejection fraction).

Treatment goals are to support cardiac output and improve coronary artery blood flow.

Signs/Symptoms/Assessment

  • Same as above
  • Pulmonary congestion
  • Chest discomfort

Interventions

  • Administer oxygen
  • Administer morphine
  • Administer vasodilators
  • Maintain patent airway
  • Administer vasopressors and positive inotropic medications
  • Treat problem–prepare for cath lab, IABP, CABG
  • Monitor I/O
  • Assist with insertion of Swan-Ganz
  • Monitor CVP, PAWP, and MAP
  • Monitor circulation (cap refill, pulses, mucous membranes)

Review Cardiac Medications Here!

Anaphylaxis

This type of shock is different from hypovolemic and cardiogenic shock. You will see that the assessment data, signs and symptoms, and interventions are also different. Anaphylaxis, or anaphylactic shock, is a sudden, severe cascade response (hypersensitivity) to an allergen. Antibodies combine with antigens and set off mast cells and histamines and cause massive vasodilation.

Signs/Symptoms/Assessment

  • Pruritus, angioedema, erythema, urticaria
  • Headache, dizziness, paresthesia, feeling of impending doom
  • Hoarseness, coughing, wheezing, stridor, dyspnea, tachypnea, sensation of narrowed airway, respiratory arrest
  • Hypotension, dysrhythmias, tachycardia, cardiac arrest
  • GI cramping, abdominal pain, N/V/D

Interventions

  • Remove the suspected allergen (stop blood transfusion, stop iodine contrast, etc.)
  • Assess respiratory status, maintain patent airway
  • notify HCP and/or rapid response team
  • administer oxygen
  • infuse normal saline (try for 2 large bore IV’s)
  • Medications: epinephrine, antihistamines (benadryl), steroids (hydrocortisone), beta-agonist
Image credit: Lonnie Millsap (lonniemillsap.com)

Neurogenic Shock

This is another type of distributive shock that impairs perfusion from vasodilation. It is most common in patients with recent injuries above T6. This can lead to pooling of blood in blood vessels.

Signs/Symptoms/Assessment

  • Hypotension
  • Bradycardia
  • Decreased cardiac output
  • Inability to sweat below the level of the injury (skin is warm and dry)

Interventions

  • Monitor vital signs
  • Notify HCP/rapid response team
  • IV fluids
  • Administer vasopressors
  • Administer atropine for bradycardia
Image source: Wikipedia

Septic Shock

Septic shock is the most extreme reaction to an infection; it is a subset of sepsis in which there is profound circulatory, cellular, and metabolic abnormalities. It is vasodilation caused by endotoxins from microorganisms.

Signs/Symptoms/Assessment

  • Tachypnea > 22 breaths/minute
  • Altered mental status – GCS < 15
  • Systolic blood pressure < 100
  • Lactic acid > 2 mmol/L
  • Unresponsive to fluid resuscitation
  • symptoms of infection – fever >100.2 F or <96.8 F

Interventions

  • Assist with placing central line
  • Monitor CVP
  • Fluid resuscitation
  • Vasopressors
  • Monitor urine output
  • Ensure cultures have been sent
  • IV antibiotics

Knowing the signs and how to manage different types of shock is essential for any nurse! I hope this review helps spark your memory for the NCLEX! Check out some of my other NCLEX review posts below:


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Stages of Labor NCLEX Review

Stage 1

Defined as the first onset of contractions through the complete dilation of the cervix, with 3 separate phases. Stage 1 is the longest phase. Throughout this phase, keep in mind the following interventions:

  • Monitor maternal and fetal vital signs.
  • Continually assess FHR before, during, and after contractions.
  • Assess fetal descent, cervical dilation, and effacement.
  • Assess fetal station presentation and position.
  • Encourage frequent position changes and/or ambulation if not contraindicated.
  • Involve patient and support person in labor process and what to expect.

Latent Phase

To start, I will add another definition here, prodromal labor. This is latent phase labor that has lasted several days.

The latent phase is usually defined by:

  • Cervical dilation is 1 to 4 cm.
  • Uterine contractions occur q15-30 mins and last 15-30 sec.
  • Lasts an average length of 5-8 hrs
  • Contractions are of mild intensity

In this stage, mom’s will most likely be feeling a variety of emotions. They are also usually able to participate in their own care and may not quite ask for pain control interventions at this time. Keep in mind that each mom is unique and requires individual assessment!

Active Phase

This phase consists of:

  • Cervical dilation of 4 to 7 cm.
  • Uterine contractions q3-5 min and last 30-60 sec.
  • Lasts an average length of 2-5 hrs.
  • Some fetal descent.
  • Contractions are moderate-strong intensity.

During this phase of labor, mom’s behavior will start to shift. She will start breathing heavier and may not be able to talk through contractions. She will benefit from a quiet environment and pain control interventions. Pain interventions do not have to be medication, as promoting comfort with back rubs, sacral pressure, and position changes can be effective and beneficial.

Transition Phase

This phase is arguably the “most difficult” phase of labor.

  • Cervical dilation is 8 to 10 cm.
  • Uterine contractions occur q2-3 min and last 45-90 sec in duration.
  • The contractions are of strong intensity.
  • Fetal descent.

During this phase, mom may have increased anxiety, apprehension, and discomfort. She will experience increased pressure, bloody show, and may verbalize the urge to push. Contrary to the active phase of labor, she may not want to be touched. Rest is encouraged between contractions.

Stage 2

Stage 2 is defined as the period from complete cervical dilation and effacement to the delivery of the fetus, or “Expulsive” phase.

  • Contractions continue to occur q2-3 min lasting 60-75 sec.
  • Increase in bloody show occurs.
  • Mom will experience voluntary or involuntary urge to “bear down.”
  • This stage can last minutes to 4 hours.

Sources of pain during the 2nd stage of labor change from pain in a more generalized area to localized to the distention of the vagina and perineum and pressure on adjacent structures.

It is important to complete assessments every 5 minutes. Normal FHR is 110-160 bpm before, during, and after contractions.

Cardinal movements of labor:

  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • Restitution
  • External Rotation
  • Expulsion

Stage 3

The process of labor does not stop once the baby has been born! This 3rd stage is from the delivery of the infant to the expulsion of the placenta. Contractions continue to occur until this is completed.
Image source: https://www.newlifeblessings.com/blog/category/placenta

  • Schultze Mechanism: “Shiny shultze” – center of the placenta separates first, and the shiny portion of the placenta emerges first.
  • Duncan Mechanism: “Dirty duncan” – the margin of the placenta separates first and the dull, rough, red portion of the placenta emerges first.

Signs of placental separation:

  • Uterus becomes globular shaped
  • Rise of the fundus in the abdomen
  • Sudden gush or trickle of blood
  • Further protrusion of the umbilical cord out of the vagina

Be sure to continue involving the mother and support person in this stage about the steps of delivering the placenta while also promoting parental-neonatal attachment. The uterine fundus should be firm and should be located 2 fingerbreadths below the umbilicus.

A placenta is considered retained if more than 30 minutes has elapsed since the birth of the infant.

Stage 4

Stage 4 is known as the Recovery Stage. This stage is defined from the delivery of the placenta to the immediate recovery of the mother.

It is important to perform maternal assessments q15min for 1 hour, q30min for 1 hour, and hourly for 2 hours, or according to facility policy. Apply ice packs to the perineum, and massage the uterus as needed to keep it firm.

The mother may also experience chills, a hypotonic bladder, and a variety of emotions related to the birth process. Encourage continued bonding between the infant and parents, and provide breast-feeding support as needed.

References and Additional Resources

All image sources are linked near or under the image on this page. I do not own the rights to images posted on this page.

Continue your NCLEX Review Journey by checking out some of my other NCLEX Review posts!


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How to Answer Priority and Delegation NCLEX Questions

Everytime I see one of these questions, I want to pull my hair out! They intimidate me and I often feel the least prepared for these types of questions. Here I will break down how to answer NCLEX-style priority and delegation questions.

A lot of this material comes from the Saunder’s Comprehensive NCLEX Review. If you’ve seen any of my other posts, you have probably run across this book. I wish I would have purchased this book my first semester of school. I bought it my third semester and kicked myself for not getting it sooner. It has been worth every penny to me!

Another great resource is the Brilliant Nurse Course for NCLEX prep. It has practice questions, detailed rationales, videos, strategy sessions, and case studies. The prices are very competitive with other similar online NCLEX-prep websites.

Priority

Prioritizing patient care is an essential nursing skill. It will determine who gets care first, and the order in which you perform your tasks. Often in the clinical setting, it can be easier to spot your priorities because you have access to a lot of information. NCLEX-style questions can be tough simply because you are given 1-2 sentences of limited information with which you must make the decision.

These types of questions can be multiple choice, select all that apply, ordered response, exhibit questions, etc. Any type of question is game!

Priority Guidelines

  • ABC’s – Airway, Breathing, Circulation
  • Remember Maslow’s Hierarchy of Needs
  • Consult your patients about their priorities and needs
  • Use the nursing process to guide you

When you are given a set of choices, read them all before making your decision. Hopefully you can eliminate 1-2 choices right off the bat. After that, use your ABC’s. If any answer choices fall into that, it is probably your answer.

Delegation

The key to answering delegation questions is understanding the scope of practice for yourself and each of your colleagues. You must also analyze the tasks that need to be done and the importance of completing them. Then, assign tasks to a competent individual.

When you assign a task to someone else, the nurse who owns the task is accountable for it.

Always ensure patient safety when delegating tasks. In general, non-invasive interventions such as ambulation and hygiene measures can be delegated to UAP’s (Unlicensed Assistive Personnel). An LPN or LVN can do some invasive procedures such as catheterization and suctioning.

Remember that a Registered Nurse is responsible for assessment, planning care, initiating teaching, and administering medications intravenously.

Never assign an unstable patient to UAP’s or LVN’s.

I hope this helps explain how to approach these questions! Practice makes perfect. Use one of the resources listed above to do practice questions! The more you expose yourself to these tough questions, the better you will get at it!


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Changing Careers (or Majors) to go to Nursing School

When I graduated high school, I wanted to be an Aerospace Engineer and work for NASA. I applied and got accepted to some of the top engineering schools in the country like University of Texas at Austin and Colorado School of Mines. I eventually chose a scholarship at the University of Colorado Boulder. My engineering journey lasted three semesters, and then I discovered that I was entirely unhappy with my life. I had a fancy engineering internship, I had great friends, and I lived in a beautiful city. What on earth could be wrong with that?

The bottom line is that engineering was not for me. It wasn’t God’s plan for me. At first I was upset that I had wasted so much time in that field, but looking back, I have used a lot of those skills in my daily life and my new nursing career.

A Diversion is Not A Waste of Time

There are so many people out there who choose nursing as a second, even third career. Some of my thoughts getting accepted into nursing school at age 24 were, “It’s about time,” and “I can’t believe I didn’t think of this sooner.”

It has taken about three semesters of school for me to be content with all of the other life choices I’ve made. I had a really rough patch, and I made a lot of choices that I regret.

If you have those types of life experiences, deal with the emotions, and use it to your advantage. I’ll use the cliche, learn from your mistakes. I am better able to handle the monstrosity of nursing school because of what I went through to get there. I would not be able to handle nursing school if I went right out of high school. I know that and I am thankful for it.

Tip: Write out your biggest life regrets/bad choices. On a separate piece of paper, write out positive lessons you learned from them. Then burn the first page with your regrets.

Have a Plan Before Quitting Your Current Job

This is something I did NOT do. Although there were many other factors in my quitting engineering school, I did not plan anything out. I left school for about a year before going back. I knew I did not want to do Aerospace, but I wanted to finish a degree. I decided to take some biology classes.

Some more life stuff happened and I switched to online, part-time school. By this time, I knew I wanted to be a nurse. I had spent so much time in the hospital that I fell in love with the art of nursing.

If I had a plan after the first time I left school, I would have been better off. But that didn’t happen. I had no idea how to start. I did zero research. I straight up just quit.

Tip: If you aren’t sure which major you want, take your basics first. Each state has different requirements, so check those out. Get your English, Math, and electives out of the way.

Do Your Research About Nursing

Nursing is a one-of-a-kind career. Nursing school is rigorous and life-changing. You will lose sleep. You will have less time with your family. You will cry. You will want to quit.

Do your research about nursing. There are a lot of misconceptions about what the job entails. If you have friends or family in nursing, ask them questions.

Listen To Your Heart

If you have a passion for it, go for it. If you are 100% sure you want to be a nurse, go for it. Any roadblocks along the way just makes it more fun when you get to your goals.

If you do all of this research and soul-searching and you still aren’t sure, you are an adult and can make your own decisions. However, I can tell you from personal experience that you need your whole heart to make it through nursing. Even when I hate school, I love it. Wouldn’t trade it for anything.

Take some time to better yourself. Read some personal development books. They are not all “if you believe it you can achieve it” cheesy. Take a look at some of my favorites below –>

Thanks for reading!



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How to Study Health Assessment in Nursing School

Assessment is one of the skills that set you apart from a lot of other medical careers. CNA’s, MA’s, Techs, and other UAP’s do not have the assessment skills that registered nurses have. It is one of those skills that is pounded in nursing school, but never truly mastered until years and years of practice. This guide will hopefully give you a better idea of how to study Assessment in Nursing School and answer HESI and NCLEX style questions.

Your textbook may be different, but we used Jarvis’s Physical Examination and Health Assessment, 7th ed.💎

Anatomy & Physiology

Most programs in the United States require A&P I and II. I’ve rarely seen some programs squish all of that in one class. You need to be a master at your anatomy and physiology. Review cardiopulmonary, abdomen, and neuro anatomy before school starts. You will need to be able to pretty much label and/or draw from memory most of your body systems. A lot of people in my class had trouble with Assessment most likely because they were weak in anatomy. I personally had trouble with the cardiovascular system for this very reason.

Vocabulary

There will be a lot of big medical terms that you’ll need to know! Hopefully you’ve picked up a lot from A&P, Patho, and your other Biology classes. When you study, make flashcards of all of the terms you do not know and study them every single day. These words WILL be on your exams, HESI, and NCLEX. Learn them now.

Normal vs. Abnormal

Assessment is all about knowing what you are supposed to be seeing, hearing, and feeling (namely inspecting, auscultating, and palpating). Establishing this foundation is very important! I took notes in two columns. One side was “normal” findings, and the other side was “abnormal” findings.

In your practice, you should be able to tell when something is wrong. You may not know 100% what is going on, but you should be able to tell your doctor over the phone what your findings are.

Study Habits + Repetition

Assessment is a tough subject. It is a lot to chew, especially with your other classes. You need to establish excellent study habits. This means no more going out every weekend, no more binge watching TV. You gotta get up earlier and go to bed later. Check out my Top 10 Study Tips to get some more tips on how to establish excellent study habits!⬇️

Repetition is key with Assessment. I probably studied each set of material more than ten times. I rewrote notes, drew pictures, and answered plenty of practice questions. I made it a goal to know the material inside and out. I probably spent the most amount of time studying for the class during my first semester.

Practice

As much fun reading out of a book is, nursing isn’t all about reading a patient’s chart. You need to practice! Practice on everyone that will let you. Friends, family, strangers (JK, that might be weird). Get used to going through your full head to toe on different people. Talk through your assessment, even if the other person has no idea what you’re saying!

Patience

These skills will come to you. Like I said in the beginning, you will not master these skills until you’ve been in practice for a long time. Don’t be too hard on yourself and don’t be afraid to seek help! As always, I am here to answer your questions!



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