ER Nursing 1-2-3: 3 Steps

Identify, anticipate, prepare — a three-step way to think about any patient, worked through a fentanyl overdose and a missed dialysis.

To better understand and manage what's happening with your patients, try using this simple 3-step approach that I rely on: 1. Identify your patient's issues, complaints, or diagnoses. 2. Anticipate what you might expect based on those issues. How can you stay one step ahead and be proactive? 3. Prepare for the worst-case scenario. What are the possible complications, and how can you monitor for them or help prevent them?

Example 1: Fentanyl Overdose

Your patient arrived after a suspected fentanyl overdose. He was found unresponsive and required multiple doses of Narcan. He is now fully awake and alert (GCS 15), maintaining his airway, and breathing deeply on his own. The last dose of Narcan was given 15 minutes ago, just before he was handed off to you. 1. What are your patient's issues? This patient overdosed on an opioid, meaning his respiratory drive may still be compromised. He is at risk of respiratory failure if the effects of Narcan wear off and the opioid effects return. 2. How can you be proactive? • Have Narcan readily available at the bedside in case it's needed again. • Place the patient on end-tidal CO2 (ETCO2) monitoring to detect early signs of hypoventilation. • Consider placing the patient near the nurses' station for direct visual observation. 3. What are the worst possible complications, and how can you monitor/prevent them? The most serious risk is respiratory arrest. You're helping prevent this by: • Frequent monitoring, including ETCO2 and visual checks • Early intervention readiness, with Narcan at the bedside • Close proximity, so any change in condition is caught quickly

Example 2: Missed Dialysis

Your patient hasn't had dialysis for a week and is now complaining of feeling increasingly tired. 1. What are their issues? Dialysis replaces kidney function by removing waste, excess fluids, and balancing electrolytes. Missing dialysis can lead to: • Electrolyte imbalances (especially hyperkalemia) • Fluid overload, which may cause pulmonary edema and respiratory distress • Uremia, contributing to fatigue and altered mental status 2. How can you be proactive? • Prepare to obtain an ECG to assess for any signs of hyperkalemia (e.g., peaked T-waves). • Request a VBG, which often results quickly and gives a rough estimate of potassium. • If potassium is high, anticipate potential interventions (e.g., calcium, insulin with D50, albuterol). • Notify the dialysis nurse early — dialysis is the definitive treatment. • If the patient shows signs of respiratory distress, suspect fluid overload and consider noninvasive ventilation (BiPAP or CPAP). Call respiratory therapy and have the machine ready. 3. What are the worst possible complications, and how do we monitor or prevent them? • Deadly arrhythmias from high potassium -> monitored with ECG and treated early. • Respiratory failure from fluid overload -> prevented with close monitoring, early RT involvement, and readiness for BiPAP/CPAP.

So Remember, ER Nursing in 3 Steps

1. Identify your patient's issues, complaints, or diagnoses. 2. Anticipate what you might expect based on those issues. How can you stay one step ahead and be proactive? 3. Prepare for the worst-case scenario. What are the possible complications, and how can you monitor for them or help prevent them?

ER Nursing 1-2-3: 3 Steps