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Ep209: Why Does ED Report Suck So Bad? or Why Do Floor Nurses Ask So Many Damn Questions?

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So all my floor and ICU nurses . . .

Ever get a report from ED that sounded something like this:

“Older female, came in with acute ischemic stroke, started tPA at 20:30, NIH 18, L side weakness, vented, VSS”?

As an ICU or floor nurse we are left thinking . . . what the hell?  What about everything else!?!

Ever wonder why report between service lines is so different?

We all have a different job and a different focus.

In this episode we talk about the differences in nursing report between ED, ICU, and the floor .  .  . and why those differences are important . . . and GOOD.

Click above to listen.  We also created a huge database of nursing report and brain sheets which you can get here.

ED vs ICU vs The Floor

There is a strange competition between different floors in the hospital.

Because other floors do things differently  . . .  we assume they do it the wrong way.

It doesn’t have to be this way!

This competition and cliqueiness has always been funny/sad to me.

Our team here at NRSNG comes from a wide range of service areas in the hospital including:

  • Peds
  • ICU
  • ED
  • MedSurg
  • Progressive Care

And you know what’s crazy??  We all get along!  We all respect the skills and specialization of the other nurse.

The reason report and care is so different on each floor is because the patient has vastly different needs as they progress through the hospital.

The ED nurse didn’t see the Stage 2 pressure ulcer on the cocyx of the Acute MI patient because . . . they didn’t look . . . and you know what??? That’s okay.  They are in the middle of saving a patient from dying of a heart attack.

Scroll up listen to the episode and be nice to your fellow nurse!

Happy Nursing!

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Podcast Transcription

All right, now let’s roll into the show. Today, we have something kind of fun to do. We’ve got Katy and Susan here today. As you guys know, Susan is an emergency room nurse. My experience is neural ICU, Katy has experience on the floor, as well as in neural ICU. What we wanted to talk about, I think a lot of times nursing professors talk about doing your full head to toe assessment. They’ll sit there over your watching you do the full head to toe assessment. I think what can sometimes get lost in doing those full head to toe assessments, is the bigger picture. Like, what kind of patient are you actually taking care of. What kind of floor are you actually on. You’re spending as much time assessing a bruised toe, as you are the lungs of a COPD patient. I think we can really get lost in that in nursing school.

 

I’m not trying to take away from what your professors have taught you and things like that. We want to show you a little bit real life, what’s going to happen with a patient that comes into the hospital. How it’s going to be different on the different floors in real life. This is unrehearsed, unscripted. We decided to let Susan choose a patient that comes into the hospital, and she’s going to show you what an ED report looks like. Patient comes in, what happens, and what her assessment really is with that patient. Really focusing on that. Then I want you guys to listen to what she’s going to do, and then listen to Katy and I as we talk about when they get to the ICU, how it’s different. I want you guys to try to listen for the differences, then we’re going to have Katy talk again what happens once that patient moves to the floor. Go ahead Susan.

 

A 75 year old male comes in with right sided facial weakness and drooping, as well as right sided arm and leg weakness. His wife is with him, she’s very concerned. We can look right at the patient right away and see that there is asymmetry in the face. We ask the wife, when was the last time he was normal? The wife says, 30 minutes ago, this just started. That automatically tells me that he is likely to be a candidate for TPA if it is an ischemic stroke. I don’t need to stop, I don’t need to ask for his grand grips. I don’t need to look at his pupils with a light. I already know that he’s a candidate. I’m going to call overheard priority 1, I’m going to bring him back in with a doctor and my trauma team immediately. We’re going to get all the labs drawn, IV started on this patient. The priority is to get that patient to a CT scanner and find out if it’s a bleeding stroke, a hemorrhagic stroke, or an ischemic stroke. I’m just going to say that word wrong apparently this whole entire podcast.

 

As soon as we find out … Also we’ll ask in route to the priority 1 room, or the recess bay, if he’s on any blood thinners. That’s also important. If he hit his head at any time. He’s not on blood thinners, he did not hit his head. In fact, we find out that he does not have a brain bleed, so he’s likely having an ischemic stroke. We start TPA weight based, and we have to get it from pharmacy immediately. That’s the end of it. We pass our patient off right then and there.

 

As soon as that happens, Susan’s done with her.

 

Yeah, I think that’s really important for people to understand. She’s not sitting there closely listening to lung sounds, heart sounds, feeling people’s pulses. It’s really important to understand, her priority is getting the TPA in. Well first of all finding out if he’s an appropriate candidate for TPA, and then administering it, and then passing him off. It is really important to understand, and have realistic expectations of what the ED will get done.

 

That’s what she’s going to call to you. She’s going to say, we are on our way up right now. We’re in the elevator right now. This patient just got started on TPA, and that’s all I need to know. Time that the TPA, what the NIH was. NIH, basically we didn’t talk about that, but she would have done one of those too with the ED. What a NIH is, is it’s a stroke assessment scale. It gives you a standardized number, that’s supposed to tell you severity of stroke. She’s going to that, they’re going to get him on TPA, and that’s all we get coming from ED. As soon as patient lands with us, what we know is that it was right sided weakness, TPA was started 20 minutes ago.

 

We’ll usually also have a stroke sheet involved with the time limits. With a stroke patient, you need to have every 15 minutes when you start TPA, a neural assessment, and a set of vitals.

 

Right, and so when they get to us in the ICU, Katy and I receive the patient, that’s really all we know. Now it’s our job to start finding out more. We got the TPA going, make sure they’re set up. We’re doing these Q15 minutes neural assessments. When they get to us, that’s kind of the first thing we’re going to start with, is the neural assessment. Go ahead Katy.

 

When we do the neural assessment, we’re doing this comprehensive neural exam and the patient is conscious. We’re also not just going to get an abbreviated NISS. NISS is the National Institute of Health Stroke Scale, the higher the number the worse the stroke. What we do is go through this lengthy assessment. We’re assessing their speech, their arms, their legs, their consciousness, all that kind of stuff. Much more in depth. You check out their level of consciousness, we’re checking pupils, we’re checking facial symmetry, we’re asking them to say different things, read different things. We’re assessing their vision, their visual fields, so they have a field cut. Can they see everything appropriately? It’s already, you can hear how much more detailed I’m getting than, is there facial weakness yes or no? It’s a big, big differences. I’m not even below the neck yet.

 

I don’t think it’s because necessarily ED nurses aren’t thorough, I think the difference is that a ICU nurse has received a patient where the life saving aspect has already begun. If I take time the time to assess a patient to that extent, I will not have gotten that TPA to them quick enough, and there could be some neurological damage due to that.

 

Exactly, ED’s job is to determine is there a life threatening condition, and stop the threat. Then they bring them to ICU where we can manage the threat. Then they’ll move to Med Surge where, let’s get them out of the hospital.

 

Yeah, we’re thinking more long term. It’s really important to understand that from the ED. They have some life threatening, or they have whatever the emergency is, because they’re in the Emergency Department, and those emergency room nurses are taking care of that.

 

To stabilize the patient.

 

Stabilizing, that is their priority. Then they figure out where they’re going to go from there. She gave him the TPA, and that is the number one priority in that situation.

 

It’s the most important thing, yeah.

 

After that, you’re checking drifts … Sorry.

 

This is all coming in. When a stroke patient arrives in a ICU, you have about 6 nurses in the room usually. Everybody goes to help with that. As we’re moving the patient over, the main nurse, the lead nurse whoever it is in the situation, would be starting the stroke scale. As we’re moving the patient over, taking their clothes off. It’s a really overwhelming experience for family and patient. We say family, get out of the room. We’ll come get you in half hour, hour, as we’re getting this patient settled. The patient’s going to come in with their clothes on, so all again what we’re really caring about in the first place is neural. If their brain doesn’t work, what else matters really. Honestly, so that initial neural assessment, you have the drift, the NIH stuff, that’s going to take 15 minutes probably, just doing that.

 

Right, and you’re simultaneously setting them up on the monitor, and getting their vitals and everything like that. Then, you’re doing grips, push pulls, you’re also assessing sensation. Having them close their eyes, and feeling on each side. Can they feel left, right, both, does it feel different, is it dull, sharp? We’re getting into very detailed stuff in the neural ICU. Then you do the same thing with their legs, and that’s just neural. Then you go through your head to toe, listening to lung sounds, listening to bowel sounds, checking out their EKG and seeing what that’s doing, checking out their vitals. That’s just the first assessment, and we’re doing assessments every 15 minutes for 2 hours.

 

30 minutes for 6.

 

Then every hour times 24. They’re getting at least hourly assessments.

 

Even with that though too, as this is happening you’re getting them set up on EKG. As soon as that happens, as the primary nurse your eyes drift up to the EKG, look at it really quick make sure there’s nothing you need to care about. Then at the same time, people are taking their clothes off. As you’re doing that, you’re doing your skin assessment at that moment. You’re not waiting to do a skin assessment. What I’m saying, as you’re receiving this patient you’re doing all the big assessments. I looked at my EKG, I haven’t had a chance to listen to heart sounds yet, but I know my EKG looks okay. I’m taking the clothes off, skin looks okay now, I’ll do a bigger one later. This whole time, you’re looking at the big stuff. Then maybe, yeah you listen to lung sounds when you can. Then you really start diving in deeper, and deeper, and deeper to the assessments. Receiving a patient, as I said, can take an hour, honestly.

 

Also, at the same time you got all these nurses in helping you. You got family, wife just found out about this stroke.

 

He was fine at dinner time, what happened?

 

Right, the ED stuff was quick. Then they’re all of sudden upstairs, they don’t know what’s going on. You spend a lot time, after you get the patient settled or your other nurses are helping get the patient settled, then you’re spending a lot of time educating as well.

 

Then the whole time, you’re making sure you don’t miss one of your 15 minutes neural assessments.

 

Yes, and charting all of this. Sweet Jesus, so much charting.

 

I’ll let you make your inferring there with how well that really happens. You’re trying to do all this, and the whole time you still haven’t done a full head to toe assessment yet. Once the patient’s there, you’ve forgotten about the family. You’re so busy with all this, your nursing friends start to peter out, and go away once the realize you’re okay. Then you start talking to the patient finally. That’s after a half hour or more of just figuring out what’s going on. You’re calling the doctor, hey the patient’s here, come check them out. You’re going to see the doctor come in, all they’re going to look at is neural too. I mean, the doctor doesn’t care about GI. They’re neural patients.

 

Yeah, you got to prioritize. The prioritization in the neural ICU, is we’re talking about neural first because that’s our big deficit. Then we’re going to work our way down. If you’re asking about and wanting to know about wounds and stuff, it’s like okay we’ll get there, but that’s not the priority. It’s really important to think big picture. In this stroke patient, in this immediate scenario, what is the most important thing?

 

You change your focus a little bit from ED, where ED all they cared about was getting that TPA in. Now we’re starting to look a little bit bigger picture. What will happen, the first thing you let that family in for this patient’s whose been in PO for 8 hours, they’re going to say they need food! They need food!

 

That’s always the first thing, when can they eat? He can’t manage his saliva, but when can he eat?

 

So you’ll tell them, how much do I want to tell this story? Let’s put it this way, you tell the family, look I will not feed them right now. If it gets to this, the doctor’s not going to feed them right now. If I feed them, they’re going to die. When I leave this room, it’s in your hands. If you kill them, it’s on your hands. Basically, you do not … Going back to the priority thing, the priority is neural in saving this patient. You don’t worry about the eating thing. That’s all the family sees, the family sees eating …

 

They’re diabetic, how are you going to control their sugar, do you even know what it is?

 

Exactly.

 

Yeah, that was one of the first things we checked. Something that I got into the habit too with educating my patients, especially the new admissions, because a lot of families, food is a big thing for them. It’s how they support each other, show love, it’s emotional, and whatever. It’s the one thing they feel like they can control. You’ll notice, no matter what area you’re in, from ED to the floor, the critical care unit, that a family focus is food.

 

They’re going to be sneaking in chips.

 

One thing that I found is, especially with the new patients, they’re sick. When you’re sick, do you really think about eating that much? Not really. Especially in this really acute, soon period of time right after this event.

 

You’ll notice that patients that are truly sick, aren’t eating.

 

Right.

 

I guess this gets into a whole separate podcast, but yeah all mom cares about is getting her son some food. All son cares about is feeding his old grandma, who hasn’t eaten. It just doesn’t matter.

 

You can tell how detailed the ICU is, but then we go to the floor. It’s kind of a little bit of the middle ground. It’s not going to be as near as in depth as the ICU, because it doesn’t need to be. Maybe it’s a few days later, he’s gotten his TPA, maybe some of his weakness has gotten better. His vitals are all great, we haven’t had any complications.

 

It kind of becomes, the patient has a history of stroke now. Versus this is a stroke patient.

 

Right, so okay now we’ve seen the damage that has occurred. We have seen whatever we’re going to get back immediately from the TPA. Maybe the weakness has gotten better, but it’s still there. Now we’re talking long term. We’re talking PT, OT, speech, and how that’s going to work. As opposed to this insanely in depth neural assessment that’s not really going to fluctuate as frequently as it could in that acute period of time after the stroke. In the floor, what I’m more concerned about is level of consciousness. I’m talking to him making sure he’s making sense with his words, and his level of consciousness hasn’t changed. His grips haven’t changed. Whatever asymmetry was in his face, it’s not getting worse. Same things with his legs.

 

My focus is getting him home, getting him the resources he needs, making sure he’s not getting worse. It’s much more, even just explaining that, was much quicker than the whole ICU one. You can tell between these three areas, that the level of focus is very, very different. The expectations when you’re getting or receiving, or work from these different areas, should be different. The report between critical care unit and floor, should not be the same as critical care to critical care nurse, or ED nurse to ED nurse. It’s all kind of different.

 

The purpose of this podcast is to show you, it’s important to learn how to do a full assessment. It’s important to learn how to listen to bowel sounds, it’s important to learn how to do a neural assessment. What you’re really going to have to learn, as nurse, is where to focus your assessment. I just don’t care to much about bowel sounds with an acute stroke patient. Susan in the ED, patients in here with MI, I don’t really care about their pressure ulcer right now. That’s a problem, but it’s not her problem. That’s my problem when they get to the ICU of making sure it’s packed and sealed and everything.

 

It’s not like a one size fits all assessment. I felt like in school, when I got my assessment class, I kind of walked away like okay, everybody gets the same assessment. They don’t. The ED assessment is different than the floor assessment, than the critical care assessment is. That’s the way it should be. When you walk away from that assessment class, you I just don’t want you to think that all assessments are created equal. They’re not.

 

They’re not. All right, I hope that was helpful today guys. I hope that gave you some motivation, some inspiration to go out and to be your best self. To go out and to become the nurse that you want to be. To make a difference, and to do the best work that you can. Listen, we’re here to help you along your way. At NRSNG.com our goal is to give you tools and confidence to help you in nursing school, on the Inclex, and in life.

 

One of those tools we created, it our Friday freebies. Weekly pdf cheat sheets that you can refer to on the clinical floor, in the classroom, and just throughout your entire career as a nurse. To get these cheat sheets, head on over to NRSNG.com/freebies. That’s NRSNG.com/freebies. You guys, if you need anything, we’re here for you. You can reach out to us on social media, or via email at [email protected] We want you to succeed, we want to help you along the way. We’re here to hold your hand. We’re here to give you the tools, the confidence that you need to achieve success in this journey to nurse. You guys know what time it is now. It’s time to go out and be your best self today. Happy nursing.

 

Date Published - Aug 15, 2016
Date Modified - Aug 15, 2016

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.