What do you think are the 10 most important guidelines for a nurse working in the ED? Here is one set of commandments I found on the mountaintop, but I hand it over to you for any suggested modifications, disagreements or additions. (Hmm…The management of narcotic seeking patients might be worth discussing.)

ONE: always document the care you deliver.

Legal Requirements Your documentation must reflect the patient’s care status (condition/treatment) and include nursing interventions and outcomes of care. Documentation must demonstrate accountability of practice. Remember: The Clinical Record provides proof of the quality of care given to a patient and is admissible in court as a legal document. If it isn’t documented it didn’t happen. The Process Clinical notes must meet the following criteria:

• they must be legible.
• they must be dated, timed and followed by author’s signature and designation.
• they must be a clearly identified signature. If your signature looks like spaghetti, print your name in brackets afterwards.
• each page must be labelled correctly,
• you must use only approved abbreviations as per hospital protocols. Here are some examples of acceptable medical abbreviations …not

Precisely document any information reported to a medical officer that relates specifically to a change in a patient’s condition. Record arrival date, time and mode of arrival. Obtain a thorough history and nursing assessment. Document any pre-existing conditions including allergies and their reactions. Thorough and appropriate documentation of haemodynamic observations including pain score.

TWO: listen to parents.

While it is true that some parents completely loose the plot over a microscopic splinter in the little toe, most do not. After performing a quick assessment of the child listen closely to the parents story.

THREE: reassess your patient after giving treatment.

Its all part of the nursing process. You can think of it as A Delicious PIE

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• Assessment.
• Diagnosis.
• Planning.
• Implementation.
• Evaluation.

Always reassess to gauge the efficacy of your current treatment.

FOUR: never assume a patient who is behaving erratically is drunk.

Oh boy, this can be a tough one

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FIVE: never ever ignore your gut feelings.

Is it an impending calamity? Or is it last nights vegetable vindaloo? Either way, ignore it and the outcome will be the same.

SIX: never deviate from safe and ethical nursing practice.

The Code of Ethics for nurses in Australia was first developed in 1993. In 2000, a conglomeration of nurses from the Australian Nursing Council, the Royal College of Nursing and the Australian Nursing Federation stayed up late for quite a few nights nutting out the current code which can be found here.

1. Nurses respect individual’s needs, values, culture and vulnerability in the provision of nursing care.
2. Nurses accept the rights of individuals to make informed choices in relation to their care.
3. Nurses promote and uphold the provision of quality nursing care for all people.
4. Nurses hold in confidence any information obtained in a professional capacity, use professional judgement where there is a need to share information for the therapeutic benefit and safety of a person and ensure that privacy is safeguarded.
5. Nurses fulfil the accountability and responsibility inherent in their roles.
6. Nurses value environmental ethics and a social, economic and ecologically sustainable environment that promotes health and well being.

SEVEN: do not accept a doctors orders without question if you have a problem with them.

Doctors are sometimes dumb as stumps. Just like us.

EIGHT: work as a team.

1. There is no “I” in: emergency department. There is, however, a “team”.
2. There are more than enough “I”s in: I’m in deep shit again.

NINE: filter for suspicions of child, spouse or elder abuse.

Our hospital’s Health Child Protection Policy requires all its staff to make a mandatory report to Care and Protection Services should they suspect non-accidental injury, sexual abuse, emotional abuse or neglect in the course of their work. It happens more than you would wish.

TEN: pain is a four letter word.

Get rid of it. I remember in the bad old days we used to leave our patients rolling around in agony until a doctor could get to them under the pretence that if we got rid of the pain, the doctor would not be able to properly assess them. What a load of bollocks. No patient should be left in pain. Use a visual or numeric analogue scale (VAS) to obtain a subjective rating of the pain from the patient. Try not to be judgemental of their response. Think they are narcotic seeking? Makes no nevermind. Control the patients subjective discomfort and then you can sort out the rest. (if the patient has known, documented history of repeated narcotic seeking behaviours, they should have a management plan developed in co-operation with drug and alcohol, and pain management specialities.) There are many different strategies for effective pain management (which I will leave for another post.) and a wide spectrum of interventions that can be implemented. How much should I give? In cases of severe pain. Many nurses are hesitant to give large accumulated doses of narcotic analgesia in case they kill their patient or get them addicted. Here is a quick guide as to a safe analgesia regime:

1. Observe them closely.
2. Keep giving aloquats of narcotic analgesia as per your hospital protocol until A) the pain score approaches zero OR B) they are too drowsy to give you a pain score.
3. If pain remains uncontrolled consider patient controlled analgesia.(PCA)
4. Ensure you have oxygen, airway adjuncts and Naloxone available.